Is Femoral Nerve Block Superior to Fascia Iliac Block in Hip Surgery? Meta-Analysis of Randomized Controlled Trials

Li, Xiao-dan; Han, Chao; Yu, Wen-li

doi:https://doi.org/10.1155/2022/4840501

BioMed Research International

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Abstract Introduction Methods Results Discussion Conclusion Abbreviations Conflicts of Interest Authors’ Contributions Acknowledgments References Copyright Related Articles

Review Article | Open Access

Volume 2022 | Article ID 4840501 | https://doi.org/10.1155/2022/4840501

Is Femoral Nerve Block Superior to Fascia Iliac Block in Hip Surgery? Meta-Analysis of Randomized Controlled Trials

Xiao-dan Li,¹Chao Han,²and Wen-li Yu¹

Academic Editor: Ayhan Comert

Received03 Aug 2021

Revised29 Mar 2022

Accepted27 Apr 2022

Published19 May 2022

Abstract

Background. Femoral nerve block (FNB) and fascia iliac compartment block (FICB) are alternative methods of pain relief during hip surgery. Nevertheless, the effectiveness and safety of FNB compared with FICB are yet to be fully determined. Methods. Electronic databases were systematically searched. Only randomized controlled trials (RCTs) on hip surgery were included. Postoperatively, the pain scores at different time points, narcotic requirements in 24 h, mean arterial pressure, spinal anesthesia (SA) time, patient satisfaction, and adverse effect rates between the two groups were extracted throughout the study. Results. Fourteen RCTs including 1179 patients were included. Compared to the FICB, FNB decreased the VAS scores postoperatively at 24 h at rest () and the incidence rate of some side effects (nausea, vomiting, and sedation) (). However, compared to the FICB, no significant difference was found in the FNB regarding the VAS scores postoperatively at any of the other time points (2 min, 20 min, 2 h, 24 h at movement, 48 h at rest, and 48 h at movement). Patients in both groups had similar narcotic needs after 24 h, mean arterial pressure, SA time, and patient satisfaction (). Conclusions. FNB has more advantages in reducing VAS scores postoperatively at 24 h at rest and the odds of some adverse effects. A better quality RCT is needed to properly compare FNB with FICB.

1. Introduction

Hip surgery-related pain occurs often, and it is commonly treated poorly because of the patient’s advanced age, comorbidities, and increased sensitivity to the side effects of analgesics [1]. Although it may be helpful to improve the surgical techniques and the perioperative period management, many patients still suffer from tremendous pain after hip surgery. A number of complications, such as lower limb deep venous thrombosis and bedsore, can arise as a consequence of postoperative procedures, causing hospitalization and increased medical costs [2]. It is crucial in clinical practice that the appropriate management is adopted to manage postoperative pain under such circumstances [3].

The postoperative pain score, the dose of the analgesic required, the mean arterial pressure, and the time during which anesthesia was administered, as well as the incidence of anesthesia-related adverse effects, were often applied to evaluate the effect of anesthesia [4–6]. The patient may experience intractable postoperative pain if inappropriate methods of anesthesia were used [7]. The use of peripheral nerve blocks as a pain management strategy has been recommended following hip surgery due to the adverse effects of opioid analgesics [3]. Under such circumstances, a femoral nerve block (FNB) and fascia iliac block (FICB) have been proven to result in a lower rate of complications and better pain control in the elderly [8].

Several studies have been conducted in the past decades on the effects of FNBs and FICBs, perioperatively [9–11]. While some conclusions have been made, whether FNB is equivalent to FICB in pain relief for hip surgery has rarely been studied through meta-analyses. The aim of this study was to compare the effects of FNB and FIB on the reduction of pain and side effects in randomized controlled trials (RCTs).

2. Methods

The PRISMA statement [12] was followed for this meta-analysis. Since this was a report on the published literature, no ethical approval was required. A comprehensive list of all literature identified by electronic searches, including MEDLINE (1966–present), EMBASE (1966–present), and Cochrane Central Register of Controlled Trials. To increase the search accuracy, the following keywords were combined with MeSH terms: “pain management, postoperative pain, hip surgery, hip fractures, femoral fractures, hip replacement, hip arthroscopy, FNBs, and fascia iliac compartment blocks.” Only RCTs in humans have been conducted up to August 2021. PRISMA Flow Diagram (Figure 1) is seen below.

2.1. Inclusion Criteria

Literature was considered eligible for inclusion if it satisfied the following requirements: types of studies: RCTs and reports in English; population: hip surgery patients; types of interventions: FNB and FICB; and types of outcomes: a minimum of one of the following items was reported: total morphine consumption, visual analog scale (VAS) score, spinal anesthesia (SA) time (as defined as time from the start of positioning to drug injection completion), mean arterial pressure, patient satisfaction, and side effects.

2.2. Exclusion Criteria

Patients with neoplasms, severe osteoporosis, infections, metal sensitivity, and mental diseases were excluded from this study.

2.3. Selection Criteria

Two independent reviewers conducted the eligibility assessments. A dispute between reviewers was resolved through discussion; if there was no consensus, the third reviewer made the final decision. The RCTs were evaluated using funnel plots to determine the risk of bias according to the Cochrane Collaboration tool [13].

2.4. Data Extraction

A pooled analysis of data from the included studies was independently performed by two authors (Xiao-dan Li and Chao Han). Data from the following sources were extracted and analyzed: first author’s name, anesthesia type, types and methods of narcotics, pain assessment methods, and adverse reactions are all listed along with the publication year. Data that could not be clarified or were incomplete were contacted by the authors to retrieve missing information.

2.5. Statistical Analysis

The pooled data were analyzed using RevMan5.3 (Cochrane Collaboration, Oxford, UK). and values were calculated using the chi-square test to measure heterogeneity. and were defined as having no significant heterogeneity, and an analysis of data using fixed-effects models was then conducted. In the case of significant heterogeneity, an effect model with random effects was applied. The mean difference (MD) and 95% confidence intervals (CIs) of continuous outcomes, such as VAS scores and narcotic consumption, were pooled to make reports. The relative risks were calculated with 95% CIs for dichotomous data, such as vomiting and nausea. Statistical significance was set at .

3. Results

3.1. Literature Search

An electronic search yielded 861 potential records, including 229 duplicate articles. Six hundred and eighty-eight articles were identified as irrelevant by the titles and excerpts, leaving fourteen studies that eventually met the eligibility requirements [4–6, 14–24]. The 14 RCTs enrolled 590 patients on the FNB group and 588 patients on the FICB group. Publications took place between 2011 and 2020.

3.2. Study Characteristics

As shown in Table 1, the included studies were characterized by the following key characteristics: all available literature consists of relatively small sample sizes, ranging from 10 to 85 patients. Preoperatively nerve block was applied in 13 studies [4–6, 14–18, 20–24], and postoperative nerve block was used in 1 study [19]. 5 studies [6, 16, 20, 22, 23] employed the general anesthesia, 4 studies [4, 5, 14, 19] used regional anesthesia, and 5 studies [15, 17, 18, 21, 24] did not mention the detailed method of anesthesia. Fentanyl was used for standard general anesthesia. Two groups of statistical characteristics were analyzed.

3.3. Assessment of Risk Bias

All included RCTs were evaluated for bias using the Cochrane Collaboration tool. Figure 2 shows a quality assessment of the methodology. All included studies had a low risk of bias.

4. Outcomes for Meta-Analysis

4.1. Postoperative VAS Scores at Different Time Points

Details regarding postoperative VAS at different time points (2 min, 20 min, 2 h, 24 h at rest, 24 h at movement, 48 h at rest, and 48 h at movement) were available in 12 trials [4–6, 15–22, 24]. Significant heterogeneity was found () in the VAS at 2 h, VAS at 24 h at rest, and VAS at 24 h at movement. The results showed that compared to the FICB, the FNB could decrease the VAS postoperatively at 24 h at rest (, 95% CI: -0.86 to -0.06, ). There was no significant difference in the FNB compared with the FICB at the rest time points postoperatively (2 min, 20 min, 2 h, 24 h at movement, 48 h at rest, and 48 h at movement) (, 95% CI: -0.12 to 0.28, ) (, 95% CI: -0.54 to 0.07, ) (, 95% CI: -1.21 to 0.75, ) (, 95% CI: -1.04 to 0.72, ) (, 95% CI: -0.30 to 0.11, ) (, 95% CI: -0.60 to 0.11, Figure 3).

4.2. Narcotic Requirements at 24 h

There were four trials that reported details of narcotic consumption [18, 20, 22, 23]. In the meta-analysis, a significant heterogeneity was found (), and no significant differences were shown in the FNB groups compared with the FICB group in reducing narcotic consumption at 24 h (, 95% CI: −0.30 to 1.20, Figure 4).

4.3. SA Time

Three trials evaluated the SA time in the two groups [4, 5, 14]. Significant heterogeneity was found (); the random model was used. Compared with the FIBC group, no significant difference in SA time was found in the FNB group (, 95% CI: -61.28 to 43.03, ; Figure 5).

4.4. Mean Arterial Pressure (mmHg)

Two trials compared the mean arterial pressure in two groups [6, 17]. Heterogeneity did not appear to be significant (), a fixed model was made. Compared with the FIBC group, no significant difference in the mean arterial pressure was found in the FNB group (, 95% CI: -5.00 to 2.79, ; Figure 6).

4.5. Patient Satisfaction

Details regarding patient satisfaction were available in four trials [5, 14, 16, 22]. No significant heterogeneity was found (), and a fixed model was performed. No significant difference was found between the groups (relative rate 0.99, 95% CI: 0.84 to 1.17, ; Figure 7).

4.6. Adverse Effects (Nausea, Vomiting, and Sedation)

Three studies reported nausea, vomiting, and sedation statistics [4, 6, 17]. Significant heterogeneity was not found in the included studies; therefore, a fixed-model was used (). Compared with FICB, FNB could significantly decrease the incidence of nausea, vomiting, and sedation, respectively (relative rate 0.30, 95% CI: 0.12 to 0.79, ) (relative rate 0.13, 95% CI: 0.02 to 0.71, ) (relative rate 0.40, 95% CI: 0.18 to 0.88, ; Figure 8).

5. Results of Reporting Bias

A funnel plot was used to evaluate reporting bias. The diagram (Figure 9) demonstrates a low risk of publication bias. Egger’s () and Bagger’s tests () were also used to measure the level of reporting bias. In our meta-analysis, no reporting bias was observed.

6. Discussion

By analyzing the pooled data, we aimed to evaluate the relevant literature effectively and provide a better understanding of the usefulness of FNB and FICB for hip surgery. Our overall results show that FNB has more advantages in reducing VAS scores postoperatively at 24 h at rest and the incidence rate of nausea, vomiting, and sedation, respectively. The low incidence of those side effects can not only effectively improve patient satisfaction but also help patients recover faster after surgery [25]. Our meta-analysis confirms previous studies reporting decreased postoperative side effects associated with FNB [3, 26, 27].

The VAS score can serve as a good indicator of the extent of postoperative pain relief following hip surgery. Our work revealed that both FNB and FICB could alleviate pain, and FNB showed stronger analgesic ability at 24 h at rest postoperatively. However, no significant differences were observed at the other time points (2 min, 20 min, 2 h, 24 h at movement, 48 h at rest, and 48 h at movement). A wide range of factors may contribute to this, such as the severity of the fracture, type of surgery, and complications of the patient. Postoperatively, only patients in good condition can undergo early rehabilitation. As a result of better pain management, therapy costs and time can be reduced, which has a profound effect on patient recovery [28].

Decreasing opioid usage is important for better patient recovery. To assess the safety of FNB and FICB in the clinic, opioid requirements at 24 h were often employed. The UK National Institute of Health and Care Excellence recommends peripheral nerve block as an opioid-saving strategy. Both FNB and FIB were able to substantially minimize opioid consumption in this part, and no significant differences were observed between them. As with previous studies, our findings are in line with those of others [29, 30].

SA time, mean arterial pressure, and patient satisfaction were the common indices in the postoperative period to compare the efficacy between FNB and FICB. As shown in Figures 5–7, FNB and FICB shared a similar ability to handle these issues. Better pain relief, shorter time for SA, and more stable mean artery pressure with FNB and FICB are well reflected in the satisfaction of the patient perioperatively. The present study is comparable to previous studies that showed that FNB or FICB was more effective in decreasing pain, shortening the time to perform SA, and increasing patient satisfaction [30, 31].

To our knowledge, this meta-analysis is the first to compare the differences between FNB and FICB in the treatment of hip surgery. Since observational and retrospective studies have their limitations, all included studies were RCTs. Nevertheless, the heterogeneity of these studies may be determined by the study design and analysis methods. One limitation of the meta-analysis is that some variables such as hip surgery type, length of operation, and complications may also have a significant impact on the degree of pain, different types of anesthetics and dosages were used, and the levels varied between 15 mL and 50 mL for the various trials. Therefore, it is necessary to further investigate the optimal use of FNB and FICB.

Finally, because almost all the studies included in the review were conducted by anesthetists, several important details such as operative procedures, types, and methods of the operation were not reported. In future studies, it is necessary to take these factors into account, because this information may often be crucial for surgeons and directly affect the degree of postoperative pain.

7. Conclusion

According to this meta-analysis of RCTs, FNB helped to reduce VAS at 24 h at rest postoperatively and side effects (nausea, vomiting, and sedation) compared to the FICB. No significant difference was found in VAS at the rest of the time points, a narcotic requirement in 24 h, SA time, mean artery pressure, and patient satisfaction between FNB and FICB. More high-quality RCTs are necessary for proper comparisons of the efficacy and safety of FNB and FICB.

Abbreviations

FNB:	Femoral nerve block
FICB:	Fascia iliac compartment blocks
VAS:	Visual analog scale scores
SA:	Spinal anesthesia
PRISMA:	Preferred Reporting Items for Systematic Reviews and Meta-analyses
RCTs:	Randomized controlled trials
MD:	Mean difference
CI:	Confidence intervals
RR:	Relative risk.

Conflicts of Interest

The authors have no competing interests to declare.

Authors’ Contributions

X.D.L and C.H. conducted the literature search and determined the studies for exclusion and inclusion. X.D.L and C.H. extracted data from the included studies, performed the meta-analysis, and drafted the manuscript. X.D.L and W.L.Y. conceived the idea of the study, designed the study, and critically revised the manuscript for important intellectual content. All authors reviewed and approved the final manuscript. Xiao-dan Li and Chao Han contributed equally to this work.

Acknowledgments

This study was supported by (1) Tianjin Enterprise Postdoctoral Innovation Project Funding (no. TJQYBSH2018020), (2) the Scientific and Technological Talent Cultivation Project of the Tianjin Municipal Health Commission (no. RC20112) and (3) Science and Technology Foundation of Tianjin Health Bureau (ZC20052).

References

B. Dasch, H. G. Endres, C. Maier et al., “Fracture-related hip pain in elderly patients with proximal femoral fracture after discharge from stationary treatment,” European Journal of Pain, vol. 12, no. 2, pp. 149–156, 2008.
View at: Publisher Site | Google Scholar
N. B. Foss, M. T. Kristensen, B. B. Kristensen, P. S. Jensen, and H. Kehlet, “Effect of postoperative epidural analgesia on rehabilitation and pain after hip fracture surgery: a randomized, double-blind, placebo-controlled trial,” Anesthesiology, vol. 102, no. 6, pp. 1197–1204, 2005.
View at: Publisher Site | Google Scholar
J. M. Garlich, A. Pujari, Z. Moak et al., “Pain management with early regional anesthesia in geriatric hip fracture patients,” Journal of the American Geriatrics Society, vol. 68, no. 9, pp. 2043–2050, 2020.
View at: Publisher Site | Google Scholar
M. Bantie, S. Mola, T. Girma, Z. Aweke, D. Neme, and A. Zemedkun, “Comparing analgesic effect of intravenous fentanyl, femoral nerve block and fascia iliaca block during spinal anesthesia positioning in elective adult patients undergoing femoral fracture surgery: a randomized controlled Trial,” Journal of Pain Research, vol. 13, pp. 3139–3146, 2020.
View at: Publisher Site | Google Scholar
A. Ghimire, B. Bhattarai, S. Koirala, and A. Subedi, “Analgesia before performing subarachnoid block in the sitting position in patients with proximal femoral fracture: a comparison between fascia iliaca block and femoral nerve block,” Kathmandu University Medical Journal, vol. 13, no. 50, pp. 152–155, 2015.
View at: Google Scholar
Y. Zhou, W. C. Zhang, H. Chong et al., “A prospective study to compare analgesia from femoral obturator nerve block with fascia iliaca compartment block for acute preoperative pain in elderly patients with hip fracture,” Medical Science Monitor: International Medical Journal of Experimental and Clinical Research, vol. 25, pp. 8562–8570, 2019.
View at: Publisher Site | Google Scholar
R. Cowan, J. H. Lim, T. Ong, A. Kumar, and O. Sahota, “The challenges of anaesthesia and pain relief in hip fracture care,” Drugs & Aging, vol. 34, no. 1, pp. 1–11, 2017.
View at: Publisher Site | Google Scholar
M. Gottlieb and B. Long, “Peripheral nerve block for hip fracture,” Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine, vol. 28, no. 10, pp. 1198-1199, 2021.
View at: Publisher Site | Google Scholar
M. D. Neuman, N. M. Elkassabany, J. Ochroch et al., “Nerve block use after hip fracture versus elective hip or knee arthroplasty: retrospective analysis,” Journal of the American Geriatrics Society, vol. 68, no. 4, pp. 835–840, 2020.
View at: Publisher Site | Google Scholar
E. F. Binder, “Nerve block use after hip fracture: missed opportunities to improve pain management?” Journal of the American Geriatrics Society, vol. 68, no. 4, pp. 689-690, 2020.
View at: Publisher Site | Google Scholar
B. A. Evans, A. Brown, G. Fegan et al., “Is fascia iliaca compartment block administered by paramedics for suspected hip fracture acceptable to patients? A qualitative study,” BMJ Open, vol. 9, no. 12, article e033398, 2019.
View at: Publisher Site | Google Scholar
D. Moher, A. Liberati, J. Tetzlaff, and D. G. Altman, “Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement,” International Journal of Surgery, vol. 8, no. 5, pp. 336–341, 2010.
View at: Publisher Site | Google Scholar
J. P. Higgins, D. G. Altman, P. C. Gotzsche et al., “The Cochrane Collaboration's tool for assessing risk of bias in randomised trials,” BMJ, vol. 343, 2011.
View at: Publisher Site | Google Scholar
Y. Liang, L. Lv, L. He, W. Deng, C. Chen, and J. Li, “A randomized controlled trial of FNB versus FICB for patients with femoral neck fractures before spinal anesthesia,” Clinical Interventions in Aging, vol. 15, pp. 1113–1119, 2020.
View at: Google Scholar
A. L. Cooper, Y. Nagree, A. Goudie, P. R. Watson, and G. Arendts, “Ultrasound-guided femoral nerve blocks are not superior to ultrasound-guided fascia iliaca blocks for fractured neck of femur,” EMA-Emergency Medicine Australasia, vol. 31, no. 3, pp. 393–398, 2019.
View at: Publisher Site | Google Scholar
B. Yu, M. He, G. Y. Cai, T. X. Zou, and N. Zhang, “Ultrasound-guided continuous femoral nerve block vs continuous fascia iliaca compartment block for hip replacement in the elderly: a randomized controlled clinical trial (CONSORT),” Medicine (Baltimore), vol. 95, no. 42, article e5056, 2016.
View at: Publisher Site | Google Scholar
D. Lončar Stojiljković, M. P. Stojiljković, R. Golijanin, S. Novaković-Bursać, and R. Škrbić, “Comparative postoperative analgesia with femoral nerve block '3-in-1' and with fascia iliaca compartment nerve block after hip alloarthroplasty,” Medicinski Casopis, vol. 50, no. 1, pp. 12–16, 2016.
View at: Publisher Site | Google Scholar
P. Reavley, A. A. Montgomery, J. E. Smith et al., “Randomised trial of the fascia iliaca block versus the '3-in-1' block for femoral neck fractures in the emergency department,” Emergency Medicine Journal, vol. 32, no. 9, pp. 685–689, 2015.
View at: Publisher Site | Google Scholar
M. Temelkovska-Stevanovska, V. Durnev, M. Jovanovski-Srceva, M. Mojsova-Mijovska, and S. Trpeski, “Continuous femoral nerve block versus fascia iliaca compartment block as postoperative analgesia in patients with hip fracture,” Korean Journal of Pain, vol. 35, no. 2, pp. 85–93, 2014.
View at: Publisher Site | Google Scholar
S. Deniz, A. Atım, M. Kürklü, T. Çaycı, and E. Kurt, “Comparison of the postoperative analgesic efficacy of an ultrasound-guided fascia iliaca compartment block versus 3 in 1 block in hip prosthesis surgery,” Aǧrı, vol. 26, no. 4, pp. 151–157, 2014.
View at: Publisher Site | Google Scholar
B. Newman, L. McCarthy, P. W. Thomas, P. May, M. Layzell, and K. Horn, “A comparison of pre-operative nerve stimulator-guided femoral nerve block and fascia iliaca compartment block in patients with a femoral neck fracture,” Anaesthesia, vol. 68, no. 9, pp. 899–903, 2013.
View at: Publisher Site | Google Scholar
S. B. Thorsten Möller, M. Huber, I. Bentrup et al., “A randomized and observer blinded comparison of continuous femoral block and fascia iliaca compartment block in hip replacement surgery,” Journal of Anesthesia & Clinical Research, vol. 4, no. 1, pp. 1–7, 2011.
View at: Google Scholar
R. E. Blackwell, M. Kushelev, J. Norton, R. Pettit, and W. K. Vasileff, “A comparative analysis of the quadratus lumborum block versus femoral nerve and fascia iliaca blocks in hip arthroscopy,” Arthroscopy, Sports Medicine, and Rehabilitation, vol. 3, no. 1, pp. e7–e13, 2021.
View at: Publisher Site | Google Scholar
J. R. Ortiz-GÓmez, M. PerepÉrez-Candel, A. Pavon-Benito et al., “A randomized clinical trial comparing six techniques of postoperative analgesia for elective total hip arthroplasty under subarachnoid anesthesia with opioids,” Minerva Anestesiologica, vol. 87, no. 6, 2021.
View at: Publisher Site | Google Scholar
D. Dillane and J. Green, “Anesthesia technique and outcomes after hip fracture surgery,” JAMA, vol. 312, no. 17, pp. 1801-1802, 2014.
View at: Publisher Site | Google Scholar
M. D. Neuman, S. S. Ellenberg, F. E. Sieber et al., “Regional versus general anesthesia for promoting independence after hip fracture (REGAIN): protocol for a pragmatic, international multicentre trial,” BMJ Open, vol. 6, no. 11, article e013473, 2016.
View at: Publisher Site | Google Scholar
T. Nishi, T. Maeda, T. Imatoh, and A. Babazono, “Comparison of regional with general anesthesia on mortality and perioperative length of stay in older patients after hip fracture surgery,” International Journal for Quality in Health Care, vol. 31, no. 9, pp. 669–675, 2019.
View at: Publisher Site | Google Scholar
S. R. Morrison, J. Magaziner, M. A. McLaughlin et al., “The impact of post-operative pain on outcomes following hip fracture,” Pain, vol. 103, no. 3, pp. 303–311, 2003.
View at: Publisher Site | Google Scholar
J. Thompson, M. Long, E. Rogers et al., “Fascia iliaca block decreases hip fracture postoperative opioid consumption: a prospective randomized controlled trial,” Journal of Orthopaedic Trauma, vol. 34, no. 1, pp. 49–54, 2020.
View at: Publisher Site | Google Scholar
I. Helso, C. Jantzen, J. B. Lauritzen, and H. L. Jørgensen, “Opioid usage during admission in hip fracture patients-the effect of the continuous femoral nerve block,” Geriatric Orthopaedic Surgery & Rehabilitation, vol. 7, no. 4, pp. 197–201, 2016.
View at: Publisher Site | Google Scholar
D. Kumar, S. Hooda, S. Kiran, and J. Devi, “Analgesic efficacy of ultrasound guided FICB in patients with hip fracture,” Journal of Clinical and Diagnostic Research, vol. 10, no. 7, pp. UC13–UC16, 2016.
View at: Publisher Site | Google Scholar

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Copyright © 2022 Xiao-dan Li et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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