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REVIEW

CURRENT
OPINION The impact of infectious diseases consultation on
oncology practice
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Bruno P. Granwehr a and Dimitrios P. Kontoyiannis b


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Purpose of review
Traditional utilization of infectious diseases consultants by oncologists ranges from inpatient management of
a variety of acute infectious syndromes to management of ambulatory patients with acute or chronic
infections; however, there is a paucity of data to evaluate in which circumstances the impact of infectious
diseases input may be most valuable.
Recent findings
Data derived from the general population of patients emphasize the value of infectious diseases
consultation in specific infections, such as Staphylococcus aureus bacteremia, candidemia, and hepatitis C
virus infection. In addition, infectious diseases involvement has been associated with greater adherence to
guidelines (up to 34% increase), more appropriate antibiotic utilization (up to 52% increase in appropriate
duration), decreased cost and complications of care, and lower mortality (up to 17% decrease). Recent
studies suggest that bedside, formal infectious diseases consultation is more optimal than informal
interactions (e.g., e-mail, telephone, other). Furthermore, infectious diseases consultants play central roles in
antibiotic stewardship, infection control, and quality improvement, particularly in oncology centers.
Summary
Infectious diseases consultants contribute value in various inpatient and outpatient infections, decreasing
mortality, cost, and complications.
Keywords
adherence with recommendations, bacteremia, fungemia, formal infectious diseases consultation, informal in-
fectious diseases consultation

INTRODUCTION improve despite broad-spectrum antibiotics, assist-


Infectious diseases represent a complex array of ance in diagnosis, and antibiotic management in
diseases displaying the delicate interplay of host patients with drug allergies, and modification or
defense, environment, and continuously adapting change of highly active antiretroviral therapy
organisms. New organisms emerge and reemerge, (HAART) for HIV [2]. The involvement of infectious
ranging from West Nile virus to HIV to tuberculosis. diseases in inpatient specialty areas has been dem-
In addition, the population is aging, with corre- onstrated, including orthopedic and ICUs [3,4]. In
sponding increases in rates of chronic diseases and an orthopedic service in Switzerland, infectious dis-
cancer. In 2001 in Texas, 9% of patients admitted for eases consultation resulted in modification of the
infection had underlying malignancy [1]. By 2025, antibiotic regimen in 88% of cases, with 32.4%
costs of infection in cancer patients over 65 years of
a
age are estimated to increase by as much as 45% [1]. Department of Infectious Diseases, Infection Control, and Employee
Appropriate utilization of infectious diseases con- Health and bDivision of Internal Medicine, Department of Infectious
Diseases, University of Texas, M.D. Anderson Cancer Center, Houston,
sultation will play a key role in reducing the costs, as
Texas, USA
well as complications, of infection in this aging and
Correspondence to Bruno P. Granwehr, MD, MS, Department of Infec-
increasingly complex population. tious Diseases, Infection Control, and Employee Health, University of
There is a paucity of data regarding the value of Texas, M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1460,
infectious diseases consultation. Traditional areas in Houston, TX 77030, USA. Tel: +1 713 745 8631; e-mail: bgranweh@
which inpatient infectious diseases consultation is mdanderson.org
sought include critically ill patients with fever of Curr Opin Oncol 2013, 25:353–359
unknown origin and persistent infections that fail to DOI:10.1097/CCO.0b013e3283622c32

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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Supportive care

In a general infectious diseases setting in Israel,


KEY POINTS 54.3% of consults were sought for management of
 Infectious diseases consultation results in improved an established infection [7]. Viral infections,
outcomes in inpatient and outpatient settings. including cytomegalovirus and herpes simplex
virus infection, accounted for 17.3% of consults,
 Mortality of S. aureus bacteremia and candidemia is whereas skin and soft tissue infections and gastro-
reduced with infectious diseases consultation.
intestinal syndromes composed 15.2 and 7.6%,
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 Adherence with infectious diseases recommendations is respectively [7]. In contrast to the oncology set-
associated with improved outcomes. ting, in a general infectious diseases setting, post-
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travel consultation (15.5%) and infections related


 Routine infectious diseases consultation for outpatient
parenteral antibiotic therapy is associated with more to pregnancy (11%) were issues leading to consul-
appropriate utilization of antibiotics, tation [7].
including discontinuation. A study conducted in a comprehensive cancer
center described the outpatient practice of two
 Telephone, curbside, or other informal consultation is
infectious diseases specialists from 1998 to 2008.
inferior to bedside consultation, resulting in
increased mortality. Among patients referred to these two specialists,
53% had a solid tumor, 8% were severely neutro-
penic, and 17% were receiving high-dose cortico-
&&
steroids [8 ]. The services that referred patients were
discontinuation and 24.4% initiation [3]. In leukemia (15%), surgical oncology (15%), and stem
addition, there was a significant reduction in overall &&
cell transplantation (14%) [8 ]. In contrast to the
antibiotic use, with consequent savings in antibiotic general infectious diseases setting, 35% of referrals
costs [3]. In the ICU study, appropriate antibiotics (compared to 54.3% [7]) were exclusively for man-
increased from 68.8 to 83.7% and compliance with agement, whereas 42% were for diagnosis and man-
local guidelines increased from 63.4 to 83.8% with agement, and 22% for diagnosis alone [8 ]. The
&&

infectious diseases involvement [4]. In the oncology infectious diseases physicians provided alternative
setting, it is even more difficult to ascertain the diagnoses in 53% of consultations, suggesting differ-
value of the infectious diseases consultant because ent types of infection in 46% and noninfectious
oncology patients are often excluded from clinical &&
etiologies in 29% of consults [8 ]. Similar to the
studies. general infectious diseases setting, 14% of consul-
A paucity of published studies exists on the topic &&
tations were for skin and soft tissue infection [8 ]. In
of infectious diseases consultation in the cancer contrast to the general infectious diseases setting,
setting. Some data, however, exist. For example, diagnosis and/or management of pulmonary nod-
an early demonstration of the utility of infectious ules or infiltrates composed 31% of consultations,
diseases consultation in patients with cancer was a almost twice as much as the general infectious dis-
significant decrease in mortality from 20.5 to 9.9% &&
eases setting [8 ]. The infectious diseases consult-
in patients with fungemia and bacteremia [5]. In this ants initiated antimicrobial therapy in 31% and
manuscript, we discuss the impact of infectious discontinuation of antibiotics in 5% of cases [8 ].
&&

diseases consultations on the cancer patient popu- These findings, summarized in Table 1, demonstrate
lation, concentrating on direct consultation, rather the important role of infectious diseases physicians
than the indirect impact from nonpatient care in the oncology setting in optimizing the diagnostic
activities such as infection control and antimicro- and therapeutic approach to established or sus-
bial stewardship [6]. pected infection.
New innovations in outpatient care include
diagnosis and prevention of reactivation of chronic
AMBULATORY SETTING infections, such as hepatitis C virus. Exacerbation
Infectious diseases consultations are predominantly of hepatitis C viral infection was reported in 33%
sought in the inpatient setting, but outpatient con- of patients in a retrospective study of patients
sultations comprise an important component of undergoing treatment at a major cancer center,
infectious diseases practice. As patient care, includ- with increased risk of reactivation in those with
ing oncology management, is increasingly shifted hematologic malignancy (73 vs. 29%, P < 0.001),
from inpatient to outpatient settings, information lymphopenia (6 vs. 0%, P ¼ 0.01), and exposure
regarding current utilization of infectious diseases to rituximab [odds ratio (OR) 4.2 (1.6–10.9),
services will assist in establishing an appropriate P ¼ 0.004] [9]. In that same cancer center, a
role for infectious diseases consultation in the hepatitis C clinic was established, with an increase
ambulatory setting. in the number of cancer patients started on therapy

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Infectious diseases support in oncology Granwehr and Kontoyiannis

Table 1. Role of infectious diseases consultation in outpatient setting

Organism or syndrome Issues

Pulmonary nodules or infiltrates Diagnostic workup


Positive respiratory cultures for unusual pathogens: colonization vs. infection
Cellulitis and/or surgical infection Antibiotic management (duration, selection, route)
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Characterize complications or deep tissue involvement


Culture and/or serologic test Need for antimicrobials
Repeat cultures or serogy, further specialized diagnostic tests
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Hepatitis C Diagnose, characterize genotype, need for treatment


Start on treatment, monitor for reactivation while on chemotherapy
HIV Diagnosis, characterize genotype, devise treatment
Coordinate with outside providers
Modify HAART given drug–drug interactions, toxicity

&
from 3% at baseline to 19% [10 ]. Interestingly, the next section, we will examine the impact of
similar sustained virologic response rates (approxi- infectious diseases consultation in the inpatient
mately one-third) were noted in cancer patients oncology setting (Table 2).
compared with other difficult-to-treat patients,
&
such as solid organ transplant recipients [10 ,11],
even prior to availability of novel protease inhibi- BLOODSTREAM INFECTION
tors [12]. In addition to hepatitis C, the complexity The impact of infectious diseases consultation on
of HAART and chemotherapy in patients with oncology inpatients was established in the 1970s at
HIV/AIDS and malignancy presents a challenge a major cancer center, in which the mortality with
to oncologists, with many interactions potentially infectious diseases involvement for bacteremia and
leading to hepatotoxicity, neutropenia, nephro- fungemia decreased to 10.6% [5]. However, the
toxicity, or alteration in levels of HAART and/or subsequent literature describing the impact of
antineoplastic agents [13]. In summary, infectious infectious diseases consultation on management
diseases consultation plays an increasingly import- and outcomes of bloodstream infections did not
ant role in the ambulatory setting in the diagnosis specifically characterize impact on cancer patients.
and management of acute and chronic infections, In a recent study conducted in the Netherlands,
ranging from pulmonary infection to skin and soft appropriateness of empiric therapy for bacteremia
tissue infection to hepatitis C virus infection. In was described. When infectious diseases consultants

Table 2. Role of infectious diseases consultation in inpatient setting

Organism or syndrome Issues Demonstrated impact

S. aureus bacteremia Antibiotic management (duration, selection) þþþ (LOS, mortality, complications)
Identification of metastatic foci
Candidemia Antibiotic management (duration, selection) þþ (mortality, adherence to guidelines)
Identification of metastatic foci
Removal of CVC
Bloodstream infections Antibiotic management (duration, selection) þþ (mortality, identification of complications)
Identification of metastatic foci
Minimize toxicity
OPAT Discontinue unnecessary antibiotics þþþ (provide transition of care, reduce
unnecessary antibiotic use)
Optimize duration of therapy

CVC, central venous catheter; LOS, length of stay; OPAT, outpatient parenteral antibiotic therapy; S. aureus, Staphylococcus aureus.

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Supportive care

were involved in selection of the empiric regimen, infectious diseases consult service was involved in
the treatment was appropriately targeted for 75% of 77% of cases, making it less likely to detect a sig-
isolated organisms. This stands in contrast to cases nificant difference in less-common outcomes such
&&
in which infectious diseases was not consulted, as mortality in this population [22 ]. Interestingly,
where selected regimens were adequate in only the authors compared the proportion of infectious
53% of cases [14]. Based on Gram stain alone, diseases consultation with prior studies and it
92% of recommendations by infectious diseases appeared that the impact on mortality was demon-
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consultants were appropriate, increasing to 100% strated only in those with less than 51% infectious
when identification and susceptibility were avail- diseases involvement with S. aureus bacteremia
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able [14]. The setting was one in which there was a [19,21,23]. Overall, infectious diseases consulta-
close relationship between the clinical microbiology tion is associated with a significant impact on adher-
laboratory and infectious diseases consultants, with ence to standards of care, reduction in relapse of
infectious diseases becoming involved routinely in infection, and mortality in studies of bloodstream
the ICU and hematology settings [14]. In addition, infection.
infectious diseases consultants were involved in all
cases of confirmed bacteremia.
An earlier study in a Swiss hospital of blood- CANDIDEMIA
stream infection showed that infectious diseases Studies described previously included, but did not
consultation resulted in higher rates of initiation focus on, the impact of infectious diseases consul-
of therapy (100 vs. 40%, P ¼ 0.0028) and narrowing tation on patients with candidemia. A study con-
of therapy (100 vs. 50%, P < 0.001) compared with ducted in Alabama showed a 33% increase in
bloodstream infections (including fungemia) in mortality associated with variation from guidelines
which infectious diseases were not involved [15]. (57 vs. 24%, P ¼ 0.003) [24]. In addition, infectious
A more recent study from Japan demonstrated a diseases consultation resulted in a 21% reduction in
20% reduction in 6-month relapse of infective endo- 6-week mortality (18 vs. 39%, P < 0.01) [24]. A study
carditis (from 22.2 to 2.2%, P ¼ 0.02) in patients for conducted in Japan demonstrated a 34% increase
whom infectious diseases consultation was involved in 30-day survival (78 vs. 44%, P ¼ 0.04), 31%
[16]. These studies confirm the important role increase in appropriate antifungal use (81 vs. 50%,
played by infectious diseases input in diagnosis, P ¼ 0.046), and 33% increase in appropriate
management, appropriate utilization of resources, duration of therapy (95 vs. 62%, P < 0.01) [25]. A
and outcomes of bloodstream infection. more recent study conducted in Washington pre-
sented at Infectious Diseases Society of America
2010 in Vancouver, Washington, USA, showed a
STAPHYLOCOCCUS AUREUS highly significant increase in 30-day survival [haz-
BACTEREMIA ard ratio (HR) 9.03 (2.7–30.4), P ¼ 0.0004], despite a
The literature regarding Staphylococcus aureus bacter- higher severity of illness, demonstrated by APACHE
emia is the most extensive and up to date in its II scores over 20 (50 vs. 12%, P ¼ 0.003) when infec-
characterization of the impact of infectious diseases tious diseases service was consulted. The overall
consults on management and outcomes of this impact of infectious diseases consultation on blood-
common bacteria for which well established guide- stream infections is highlighted by decreased
lines are available [17,18]. Specifically, infectious mortality in S. aureus bacteremia and candidemia.
diseases consultation was shown to have a consider- The impact of infectious diseases consultation in
able impact on various aspects of S. aureus bacter- other syndromes, such as pneumonia, meningitis,
emia, including decrease in mortality (9–17% osteomyelitis, and/or cellulitis specifically in cancer
&&
reduction) [19–21,22 ], better adherence to stand- patients, has not been characterized. A study of
&&
ard of care (up to 34%) [22 ], decreased rate of patients admitted with fever due to pneumonia,
&&
relapse (9–19%) [22 ], and diagnosis of metastatic urinary tract infection, upper respiratory infection,
foci of infection or endocarditis (10–18%) [20,21]. and skin infection shows that an infectious diseases
In another published study, propensity scores were admitting team performs a more aggressive workup
used to try to closely match patient characteristics with higher rate of accurate diagnosis and appro-
associated with infectious diseases consultation priate antibiotics, but without significant impact on
&&
[22 ]. The authors found that infectious diseases mortality [26]. The value of infectious diseases con-
consultation was associated with a decreased risk of sultation in the inpatient setting continues to be a
relapse (19 vs. 10%) and increased adherence to subject of intense study, particularly as bundled
standard of care (89 vs. 55%). Impact on mortality payments, and other reductions in payment to
was not seen, but the authors noted that the hospitals are anticipated in the United States.

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Infectious diseases support in oncology Granwehr and Kontoyiannis

TRANSITION OF CARE this practice may consist of up to 17% of clinical


An area of considerable and increasing interest is the work by an infectious diseases unit [30]. Notably,
transition between inpatient and outpatient care, coding of the questions arising from these ‘curbside’
whether to a long-term care facility or the com- consultations was considered complex in nature for
munity. Infectious diseases consultation can be use- 84% of inpatient and 75% of outpatient consul-
ful in optimizing the selection and duration of tations [30].
antibiotics or even discontinuing unnecessary anti- In a large hospital in France, a hotline was estab-
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biotics. A teaching hospital in Massachusetts imple- lished for infectious diseases consultation, with for-
mented mandatory infectious diseases consultation mal consultation available on request [31]. Formal
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for patients scheduled to receive outpatient paren- consultation was more commonly requested for
teral antibiotic therapy (OPAT) [27]. The study did nosocomial infection compared with community-
not include Medicare patients because OPAT was acquired infection (44 vs. 12%, P < 0.001) [31].
not funded for that population at the time of the Recommendations were made to modify antimicro-
study. Infectious diseases consultation resulted in bial therapy in up to 36% of cases, particularly in
change in recommendations for 88.6% of patients, hospital settings [31]. The study was designed to
including change to oral antibiotics in 38.6%, dis- demonstrate the utility and volume of consultation
continuation in 2.3%, change in selection in 29.6%, to a ‘hotline’ for consultation, not to correlate the
change in dose in 11.4%, and duration of antibiotics mechanism of consultation with outcomes.
in 6.8% [27]. A study in Finland, however, sought to assess the
An institution in Ohio replicated the protocol, adequacy of telephone consultation compared to
requiring infectious diseases consultation for all bedside consultation for management of S. aureus
&&
&&
patients scheduled to receive OPAT [28 ]. Inpatient bacteremia [32 ]. The authors found that patients
consultation before discharge resulted in discon- with bedside consultation were more likely to have
tinuation of parenteral antibiotics in 28% of deep infectious foci compared with those with tele-
&&

patients [29]. Oral antibiotics were used in 17% phone consultation (78 vs. 53%, P < 0.001) [32 ]. In
and 11% did not require antibiotics [29]. In addition, mortality was lower at 7 days (1 vs. 8%,
addition, outpatient infectious diseases consul- P ¼ 0.001), 28 days (5 vs. 16%, P ¼ 0.002), and 90
tation was arranged for 75% of the patients, 86% days (9 vs. 29%, P < 0.001) in the bedside consul-
of whom were provided with outpatient parenteral tation group compared with telephone consultation
&&

therapy and 25% of those for whom outpatient [32 ]. The mortality rate was considerably higher
parenteral therapy was not felt necessary [29]. Nota- for those with no consultation vs. bedside consul-
bly, no patients were readmitted or seen in the tation as well (5 vs. 34% 28 day mortality, P < 0.001).
emergency department for the same infection On multivariate analysis, lack of infectious diseases
during 30 days of follow-up [29]. In addition, infec- consultation within 1 week [OR 3.56 (1.59–7.94),
tious diseases consultation resulted in optimization P ¼ 0.002] or telephone consultation [OR 2.31
in selection, duration, route, or discovery of psycho- (1.22–4.38), P ¼ 0.01] was associated with increased
social issues that could impact therapy (e.g., intra- 90-day mortality, compared with those patients for
venous drug use) in 84% of patients seen [28 ].
&&
whom infectious diseases performed a bedside con-
&&

Hematology and oncology service patients com- sultation [32 ]. In a recent study from the general
prised only 10% of this study population. In sum- hospitalist literature in which telephone, or curb-
mary, the implementation of routine infectious side, consultations were followed up by formal bed-
diseases consultation for OPAT patients results in side consultations, authors found that information
reduction or optimization of antimicrobial usage provided by requesting providers was inaccurate or
without increase in readmissions related to the incomplete in 51% of curbside consultations [33].
same infections. This resulted in a change of management advice for
60% of patients compared with curbside consul-
tation [33]. In summary, telephone or curbside con-
BEDSIDE OR CURBSIDE? sultation, although comprising as many as 17% of
The diagnosis and management of infectious dis- consults [30], appears inferior to bedside consul-
eases is a cognitive process that traditionally tation, providing inaccurate information [33] that
&&
requires bedside evaluation by a physician who may result in increased mortality [32 ].
obtains an in-depth history, physical examination,
and interprets the relevant radiology and laboratory
studies. Time and budget limitations have led to COMMUNICATION AND ADHERENCE
utilization of ‘curbside’ consultations rather than The impact of infectious diseases consultation
request for bedside consultation. In some settings, in various infections and syndromes is well

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Supportive care

established. The best approach for communication from S. aureus bacteremia [19] to candidemia
of recommendations and assuring adherence, how- [24,25]. The role of infectious diseases consultation
ever, continues to be explored. A survey regarding in managing the transition from inpatient to out-
preferences for consultation suggested that differ- patient settings was pointed out, including discon-
ences exist between surgical and nonsurgical teams tinuation of antibiotics, change to an oral agent, or
in preference for level of involvement, ranging from change in selection of antibiotic [27,29]. Of particu-
recommendation alone to comanagement (includ- lar note, telephone, curbside, or other informal
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ing writing medications and/or diagnostic studies) consultations were associated with lower adherence
[34]. Similarly, the preferred method of communi- to guidelines and poorer outcomes, including
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&&
cation of recommendations is verbal for 79% of mortality [32 ]. The particular knowledge and
nonsurgeons, but verbal for only 69% of surgeons expertise of infectious diseases consultants is sought
[34]. In a study in France, a survey of requesting out not only in the inpatient (Table 2), but also the
physicians showed that 89.8% requested communi- outpatient setting (Table 1), commonly resulting in
cation by cell phone, 5.7% via an office ‘secretariat,’ a significant impact on the diagnostic and/or thera-
and 4.5% via e-mail [35]. Of those seeking assistance peutic approach in a variety of documented or pre-
&&
from infectious diseases consultants, 93% were sumed infectious disease processes [8 ]. Other areas
somewhat or very satisfied with the consultations of interest include assistance in diagnosis and man-
[35]. Methods of communication are important, but agement of chronic viral infections such as hepatitis
&
other factors were explored regarding adherence C [10 ] and HIV, given the complexity of drug–drug
to recommendations. interactions [13]. Further work needs to be done
In a study conducted in France, adherence to to characterize the impact of infectious diseases
antimicrobial recommendations suggested by infec- consultation specifically for cancer patients. The
tious diseases physicians was 88.2%, with only value added by infectious diseases consultation in
72.2% adherence to diagnostic suggestions [36]. improving outcomes, reducing drug utilization,
Importantly, the study showed that adherence to length of stay, and reducing readmission in an
recommendations for treatment was associated with aging, increasingly complex cancer population,
a shorter median length of stay (20 vs. 23 days, suggests that this area is a productive direction of
P ¼ 0.03) and earlier clinical improvement (60.7 future research.
vs. 43.9%, P ¼ 0.01), but in-hospital mortality was
not affected [36]. In a recent study conducted in Acknowledgements
Spain, involving a population with 41.2% patients None.
with malignancy, both adherence to suggestions
[OR ¼ 0.35 (0.19–0.64), P ¼ 0.001] and adequate Conflicts of interest
initial treatment [OR ¼ 0.39 (0.19–0.80), P ¼ 0.01]
were associated with clinical response [37]. In sum- There are no conflicts of interest.
mary, direct verbal communication is preferred
through e-mail or written recommendations for
communication by most nonsurgical teams [34],
REFERENCES AND RECOMMENDED
and adherence to recommendations is associated
READING
Papers of particular interest, published within the annual period of review, have
with improved outcomes [36,37]. been highlighted as:
& of special interest
&& of outstanding interest

Additional references related to this topic can also be found in the Current
CONCLUSION World Literature section in this issue (p. 433).

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