Abstract MP20: The Effect of the Covid-19 Pandemic on Stroke Code Time Metrics at an Academic, Comprehensive Stroke Center

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Dawn M Meyer ◽  
Benjamin Shifflett ◽  
Reza Bavarsad Shahripour ◽  
Tamra Ranasinghe ◽  
Dolores Torres ◽  
...  
Keyword(s):  
Arrival Time ◽  
Treatment Decision ◽  
Stroke Care ◽  
Demographic Variables ◽  
Hospital Arrival ◽  
Stroke Registry ◽  
Treatment Administration ◽  
Race Ethnicity ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Introduction: The COVID-19 pandemic forced immediate changes to stroke code protocols to maintain safety of patients and providers. We hypothesize that stroke code time metrics were significantly longer in the peri-COVID stroke code activations compared to pre-COVID activations. Methods: We analyzed data from an IRB-approved, prospectively collected stroke registry at a large academic, comprehensive stroke center (CSC). We included all patients that presented as stroke code activations from June 2009-August 2020, excluding spoke telestroke and in-house codes. Pre-COVID was defined as June 1, 2009-March 11, 2020 and peri-COVID March 12, 2020 to August 11, 2020. The pre-pandemic stroke code protocol began June 2009. We assessed The Joint Commission stroke code time metrics between groups. Demographic variables of baseline NIHSS, sex, race/ethnicity, age, smoking, pertinent past medical history, arrival mode, and baseline glucose were assessed. A t-test was used to compare stroke code time metrics in minutes. All analyses were done unadjusted. Results: We assessed 813 pre and 328 peri-COVID stroke code activations. Baseline demographics were significant only for an increased number of Hispanics in the pre-COVID group (22.9% vs 11.1%, p<0.001). Onset to hospital arrival time was significantly longer in the peri-COVID compared to pre-COVID group (244 vs 110 min, p<0.001). Onset to stroke code activation was significantly longer in the peri-COVID compared to pre-COVID group (243.8 vs 116.8 min, p<0.009). Time from arrival to treatment decision was significantly decreased in the peri-COVID group (29.9 vs 39.6 min, p=0.04). Time from arrival to CT scan completed (p=0.37), arrival to treatment administration (p=0.06), and onset to treatment administration (p=0.48) were not significantly different between groups. Conclusion: The COVID-19 pandemic significantly impacted the volume and demographic of stroke patients seeking emergency care. This data supports the trend of patients delaying emergent stroke care. This academic, CSC developed and implemented a COVID-19 stroke code protocol within days of a statewide lockdown. The use of telestroke in this peri-pandemic protocol may have accounted for the significant decrease in time to treatment decision.

Abstract WP247: Facilitating Pre-hospital Communication between Neurology and Witness Reduces IV Alteplase Initiation Times

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Cortlyn J Elshire ◽  
Lindsay Olson-Mack ◽  
Jean Rockwell ◽  
Sara Deskin ◽  
Lynn Berger ◽  
...  
Keyword(s):  
Medical History ◽  
Intervention Group ◽  
Treatment Decision ◽  
Standard Of Care ◽  
Care Group ◽  
Exclusion Criteria ◽  
Hospital Arrival ◽  
Fire Stations ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Introduction: American Stroke Association guidelines recommend pre-hospital stroke code notification via EMS to facilitate prompt treatment decision for acute ischemic stroke (AIS) patients. Despite pre-notification to the stroke team, treatment decisions are often delayed until medical history and last known well times are established. Hypothesis: We hypothesized that screening for IV Alteplase candidacy and obtaining pertinent medical history from a witness or patient during a pre-hospital stroke code activation prior to hospital arrival would decrease door to needle (DTN) times. Methods: A retrospective analysis was conducted on 193 patients presenting to the emergency department (ED) at a Comprehensive Stroke Center (CSC) from February 2016 through July 2016. A process improvement (PI) event was initiated between the CSC and two fire stations with a catchment time of > 10 minutes. For pre-hospital activated stroke codes, the witness or patient was provided the contact card and encouraged to call the centralized number to the Neurologist. Inclusion criteria: All patients presenting to the ED with EMS pre-hospital stroke code activation. Exclusion criteria: Patients presenting to the ED with stroke code initiated after arrival, or medic response events which did not lead to a pre-hospital stroke code activation. Results: After applying criteria, 126 met inclusion and exclusion criteria. A total of 19 patients arrived via the 2 fire stations with pre-hospital stroke code initiations and serve as our intervention group, while 107 patients underwent standard of care. Contact cards were provided to 11 patients (58%) in the intervention group prior to arrival. IV Alteplase was initiated for 3 of 11 patients (27.3%) in the intervention group vs. 19 of 107 patients (17.8%) in the standard of care group. Mean and median DTN times in the intervention group was 36 minutes as compared to a mean of 46.1 minutes and median time of 40 minutes receiving standard of care. Conclusions: Preliminary data suggest that DTN times can be decreased when medical history is obtained prior to hospital arrival to screen for IV Alteplase eligibility. This study warrants further investigation in pre-acquisition of history for pre-hospital stroke code patients.

scholarly journals Coronavirus disease 2019 is threatening stroke care systems: a real-world study

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Jiawei Xin ◽  
Xuanyu Huang ◽  
Changyun Liu ◽  
Yun Huang
Keyword(s):  
Real World ◽  
Mainland China ◽  
Stroke Care ◽  
Hospital Length ◽  
Real World Data ◽  
Care Systems ◽  
Long Term Prognosis ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Medical Burden

Abstract Background Since the onset of the coronavirus disease 2019 (COVID-19) pandemic, the stroke care systems have been seriously affected because of social restrictions and other reasons. As the pandemic continues to spread globally, it is of great significance to understand how COVID-19 affects the stroke care systems in mainland China. Methods We retrospectively studied the real-world data of one comprehensive stroke center in mainland China from January to February 2020 and compared it with the data collected during the same period in 2019. We analyzed DTN time, onset-to-door time, severity, effects after treatment, the hospital length of stays, costs of hospitalization, etc., and the correlation between medical burden and prognosis of acute ischemic stroke (AIS) patients. Results The COVID-19 pandemic was most severe in mainland China in January and February 2020. During the pandemic, there were no differences in pre-hospital or in-hospital workflow metrics (all p>0.05), while the degree of neurological deficit on admission and at discharge, the effects after treatment, and the long-term prognosis were all worse (all p<0.05). The severity and prognosis of AIS patients were positively correlated with the hospital length of stays and total costs of hospitalization (all p<0.05). Conclusions COVID-19 pandemic is threatening the stroke care systems. Measures must be taken to minimize the collateral damage caused by COVID-19.

How do treatment times impact on functional outcome in stroke patients undergoing thrombectomy in Germany? Results from the German Stroke Registry

2021 ◽  
pp. 174749302098526
Author(s):  
Juliane Herm ◽  
Ludwig Schlemm ◽  
Eberhard Siebert ◽  
Georg Bohner ◽  
Anna C Alegiani ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Odds Ratio ◽  
Intravenous Thrombolysis ◽  
Stroke Patients ◽  
Poor Functional Outcome ◽  
Stroke Registry ◽  
Primary Stroke Center ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Center Time

Background Functional outcome post-stroke depends on time to recanalization. Effect of in-hospital delay may differ in patients directly admitted to a comprehensive stroke center and patients transferred via a primary stroke center. We analyzed the current door-to-groin time in Germany and explored its effect on functional outcome in a real-world setting. Methods Data were collected in 25 stroke centers in the German Stroke Registry-Endovascular Treatment a prospective, multicenter, observational registry study including stroke patients with large vessel occlusion. Functional outcome was assessed at three months by modified Rankin Scale. Association of door-to-groin time with outcome was calculated using binary logistic regression models. Results Out of 4340 patients, 56% were treated primarily in a comprehensive stroke center and 44% in a primary stroke center and then transferred to a comprehensive stroke center (“drip-and-ship” concept). Median onset-to-arrival at comprehensive stroke center time and door-to-groin time were 103 and 79 min in comprehensive stroke center patients and 225 and 44 min in primary stroke center patients. The odds ratio for poor functional outcome per hour of onset-to-arrival-at comprehensive stroke center time was 1.03 (95%CI 1.01–1.05) in comprehensive stroke center patients and 1.06 (95%CI 1.03–1.09) in primary stroke center patients. The odds ratio for poor functional outcome per hour of door-to-groin time was 1.30 (95%CI 1.16–1.46) in comprehensive stroke center patients and 1.04 (95%CI 0.89–1.21) in primary stroke center patients. Longer door-to-groin time in comprehensive stroke center patients was associated with admission on weekends (odds ratio 1.61; 95%CI 1.37–1.97) and during night time (odds ratio 1.52; 95%CI 1.27–1.82) and use of intravenous thrombolysis (odds ratio 1.28; 95%CI 1.08–1.50). Conclusion Door-to-groin time was especially relevant for outcome of comprehensive stroke center patients, whereas door-to-groin time was much shorter in primary stroke center patients. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT03356392 . Unique identifier NCT03356392

Impact of RapidAI mobile application on treatment times in patients with large vessel occlusion

2021 ◽  
pp. neurintsurg-2021-017365
Author(s):  
Mais Al-Kawaz ◽  
Christopher Primiani ◽  
Victor Urrutia ◽  
Ferdinand Hui
Keyword(s):  
Mobile Application ◽  
Secondary Analysis ◽  
Multiple Linear Regression Model ◽  
Stroke Care ◽  
Mobile App ◽  
Large Vessel ◽  
Vessel Occlusion ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Adjusted Model

BackgroundCurrent efforts to reduce door to groin puncture time (DGPT) aim to optimize clinical outcomes in stroke patients with large vessel occlusions (LVOs). The RapidAI mobile application (Rapid Mobile App) provides quick access to perfusion and vessel imaging in patients with LVOs. We hypothesize that utilization of RapidAI mobile application can significantly reduce treatment times in stroke care by accelerating the process of mobilizing stroke clinicians and interventionalists.MethodsWe analyzed patients presenting with LVOs between June 2019 and October 2020. Thirty-one patients were treated between June 2019 and March 2020 (pre-app group). Thirty-three patients presented between March 2020 and October 2020 (post-app group). Mann–Whitney U test and Kruskal–Wallis tests were used to examine variables that are not normally distributed. In a secondary analysis we analyzed interhospital time metrics between primary stroke centers and our comprehensive stroke center.ResultsBaseline demographic and vascular risk factors were similar in both groups. Use of Rapid Mobile App resulted in 33 min reduction in DGPT (P=0.02), 35 min reduction in door to first pass time (P=0.02), and 37 min reduction in door to recanalization time (P=0.02) in univariate analyses when compared with patients treated pre-app. In a multiple linear regression model, utilization of Rapid Mobile App significantly predicted shorter DGPT (P=0.002). In an adjusted model, National Institutes of Health Stroke Scale (NIHSS) 24 hours after procedure and at discharge were significantly lower in the post-app group (P=0.03). Time of transfer between primary and comprehensive stroke center was comparable in both groups (P=0.26).ConclusionIn patients with LVOs, the implementation of the RapidAI mobile application was independently associated with reductions in intrahospital treatment times.

Abstract WP429: A Nurse Driven Acute Stroke Alert Process Improves Treatment Times and Treatment Rates

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Daniel D'Amour ◽  
Jayme Strauss ◽  
Amy K Starosciak
Keyword(s):  
Treatment Time ◽  
Treatment Decision ◽  
Treatment Rate ◽  
Treatment Decision Making ◽  
National Rate ◽  
Number Of Patients ◽  
Stroke Team ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Positive Effect

Introduction: Treatment time has gained sufficient popularity because it is now well-known that “Time is Brain”. Treatment rates, however, lag behind in importance even though more lives can be saved by treating more often. Our TJC Comprehensive Stroke Center has a nurse-led stroke alert process that focuses on multiple, rapid, parallel steps to reduce DTN for IV alteplase. The Baptist Emergency Stroke Team (BEST) responders are highly-trained and skilled nurses that assess, coordinate, and initiate processes to ensure the best times. We identified that our treatment rate was lower than the national rate for certified CSCs, so the BEST responders used a stepwise process to develop their own interventions to improve rates. Methods: First, the BEST responders started tracking our monthly rate. Next, they set a rate goal, and then brainstormed how to influence treatment decision-making. The BEST team initiated a monthly PI meeting that focused on the importance of treating disability rather than an NIHSS score. Then the team scripted and rehearsed critical conversations to have providers that advocated specifically for treating disability. The team adopted the motto, “Treat Disability, Not Numbers”. Results Conclusions: Our CSC observed a small decrease in median DTN but double the treatment rate after the BEST responder intervention. In comparison, these statistics did not change at the national CSC level. The sICH rate was reduced from Period A to C, meaning that increased treatment rate did not lead to increased hemorrhagic rate. Nursing initiatives can have a substantial positive effect on increasing the number of patients treated with IV alteplase for acute ischemic stroke.

Detection of Large Vessel Occlusion Stroke in the Prehospital Setting

Stroke ◽  
2021 ◽  
Author(s):  
Laura C.C. van Meenen ◽  
Maritta N. van Stigt ◽  
Arjen Siegers ◽  
Martin D. Smeekes ◽  
Joffry A.F. van Grondelle ◽  
...  
Keyword(s):  
Diagnostic Accuracy ◽  
Stroke Care ◽  
Prehospital Setting ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
User Friendliness ◽  
Vessel Occlusion ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Good Diagnostic Accuracy

A reliable and fast instrument for prehospital detection of large vessel occlusion (LVO) stroke would be a game-changer in stroke care, because it would enable direct transportation of LVO stroke patients to the nearest comprehensive stroke center for endovascular treatment. This strategy would substantially improve treatment times and thus clinical outcomes of patients. Here, we outline our view on the requirements of an effective prehospital LVO detection method, namely: high diagnostic accuracy; fast application and interpretation; user-friendliness; compactness; and low costs. We argue that existing methods for prehospital LVO detection, including clinical scales, mobile stroke units and transcranial Doppler, do not fulfill all criteria, hindering broad implementation of these methods. Instead, electroencephalography may be suitable for prehospital LVO detection since in-hospital studies have shown that quantification of hypoxia-induced changes in the electroencephalography signal have good diagnostic accuracy for LVO stroke. Although performing electroencephalography measurements in the prehospital setting comes with challenges, solutions for fast and simple application of this method are available. Currently, the feasibility and diagnostic accuracy of electroencephalography in the prehospital setting are being investigated in clinical trials.

scholarly journals Impact of COVID-19 Pandemic on the Incidence, Prehospital Evaluation, and Presentation of Ischemic Stroke at a Nonurban Comprehensive Stroke Center

2021 ◽  
Vol 2021 ◽  
pp. 1-5
Author(s):  
Cesar Velasco ◽  
Brandon Wattai ◽  
Scott Buchle ◽  
Alicia Richardson ◽  
Varun Padmanaban ◽  
...  
Keyword(s):  
Urban Areas ◽  
Stroke Care ◽  
Final Diagnosis ◽  
Medical Attention ◽  
Presenting Symptoms ◽  
Number Of Patients ◽  
Community Transmission ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
The Impact

Introduction. Many reports have described a decrease in the numbers of patients seeking medical attention for typical emergencies during the COVID-19 pandemic. These reports primarily relate to urban areas with widespread community transmission. The impact of COVID-19 on nonurban areas with minimal community transmission is less well understood. Methods. Using a prospectively maintained prehospital quality improvement database, we reviewed our hospital EMS transports with a diagnosis of stroke from January to April 2019 (baseline) and January to April 2020 (pandemic). We compared the volume of patients, transport/presentation times, severity of presenting symptoms, and final diagnosis. Results. In January, February, March, and April 2019, 10, 11, 17, and 19 patients, respectively, were transported in comparison to 19, 14, 10, and 8 during the same months in 2020. From January through April 2019, there was a 53% increase in transports, compared to a 42% decrease during the same months in 2020, constituting significantly different trend-line slopes (3.30; 95% CI 0.48–6.12 versus -3.70; 95% CI -5.76–-1.64, p = 0.001 ). Patient demographics, comorbidities, and symptom severity were mostly similar over the two time periods, and the number of patients with a final diagnosis of stroke was also similar. However, the median interval from EMS dispatch to ED arrival for patients with a final diagnosis of stroke was significantly longer in January to April 2020 ( 50 ± 11.7   min ) compared to the same time period in 2019 ( 42 ± 8.2   min , p = 0.01 ). Discussion/Conclusion. Our data indicate a decrease in patient transport volumes and longer intervals to EMS activation for suspected stroke care. These results suggest that even in a nonurban location without widespread community transmission, patients may be delaying or avoiding care for severe illnesses such as stroke. Clinicians and public health officials should not ignore the potential impact of pandemic-like illnesses even in areas of relatively low disease prevalence.

Abstract WP439: "You Gotta Troll to Enroll!" Nurses Actively Scouting Patients for Clinical Trials

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Betty Robertson ◽  
Denise Levesque ◽  
Nicole Wolber ◽  
Nili Steiner ◽  
Nancy Nunez ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Anticoagulation Therapy ◽  
Training Session ◽  
Stroke Care ◽  
Patient Identification ◽  
Stroke Team ◽  
Expert Nurses ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Patient Enrollment

Problem/ Background: Evidence- based practice is the cornerstone in delivery of stroke care to optimize outcomes for patients. Research is the foundation to build and advance clinical practice. As a Comprehensive Stroke Center, we are charged with participating in IRB approved research. In 2016 the SUCCEED trial was stopped here as a result of low enrollment. The stroke nurses were not directly involved in that trial. In 2017, the stroke nurses partnered with our physicians and began the ARAMIS trial. This is a multicenter study of acute stroke patients taking anticoagulation therapy prior to admission and suffering a stroke. We recognized the need for our stroke nurses to collaborate, participate and use their expertise in identifying appropriate research patients for this study. Quality Question: Will tasking Stroke Nurses with identifying patients improve the enrollment of patients in ARAMIS trial? Methods: Stroke nurses attended an ARAMIS training session for physicians. Included in the meeting was review of inclusion/exclusion criteria for patient enrollment. A group e-mail was created for all participating in the study to help identify potential patients. When a patient was discovered an email was sent to the group alerting those responsible for obtaining consent for the study and data collection for the registry. Results: After one trial was ended due to low enrollment, the new ARAMIS trial opened. The stroke team nurses took the lead on identifying patients. Reviewing retrospective data starting in November 2017 until March 2019, 56 patients were enrolled in Aramis. Stroke nurses identified 43 patients (77%), Neurology fellows 10 (18%) and Faculty physicians 3 (5%). Conclusion: When including expert nurses in the patient identification process, the nurse plays a pivotal role in identifying appropriate patient for the MDs to enroll, thus, increasing enrollment in clinical trials. While additional tracking and trending needs to take place as new trails open, this trial makes clear the need for nurse involvement in identifying appropriate patients.

Abstract TP303: Real-world Eligibility for Revascularization in Acute Stroke: A 12 Year Single Center Statistics

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Peter Vanacker ◽  
Dimitris Lambrou ◽  
Ashraf Eskandari ◽  
Patrik Michel
Keyword(s):  
Time Windows ◽  
Standard Of Care ◽  
Stroke Care ◽  
Regional Level ◽  
Effective Number ◽  
Single Center ◽  
Resource Needs ◽  
Liberal Approach ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Aims: Endovascular treatment (EVT) for acute ischemic stroke (AIS) is the new standard of care for well selected, large vessel occlusive strokes. Hypothesis: We aimed to determine the frequency of patients potentially eligible for IV thrombolysis (IVT) and EVT based on the latest AHA/ASA guidelines. Methods: Data from a prespecified consecutive AIS registry (ASTRAL, 2003-2014) of a single comprehensive stroke center were examined. All AIS admitted <24hours and sufficient data to determine EVT-eligibility according to AHA/ASA guidelines (class I and IIa recommendations) on IVT and EVT were selected. Another set of more liberal criteria from different EVT trials and clinical practice was also tested. Time windows for EVT-eligibility was 4.5h (allowing for a door-to-groin delay ≤90min) and for IVT 3.5h (door-to-needle delay ≤60min). Results: A total of 2’704 AIS were included, of whom 26.8% were secondary transferrals. Proportion of IVT-eligible patients was 12.4% for all AIS, and 24.6% and 36.2% for patient arriving <24h and 6h respectively. Frequency of EVT-eligibility differed between the AHA/ASA guideline and the more liberal approach: 2.9% vs. 4.9% of all AIS and 10.5% vs. 17.7% of all patients arriving <6hours. These numbers are in line with the effective number of EVT applied in 2013 (15%) and 2014 (12%). Conclusions: Of patients arriving within 6h at a comprehensive stroke center, 10.5% are EVT eligible according to AHA/ASA criteria, nearly double (17.7%) with more liberal criteria, and again double for IV thrombolysis (36.2%). These figures may be useful for planning resource needs of stroke care on a regional level.

Abstract TP414: Support from a Comprehensive Stroke Center Improves Door to tPA Times at Primary Stroke Centers

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Julie M Fussner ◽  
Kelly Montgomery ◽  
Tinatin Gumberidze ◽  
Erin Supan
Keyword(s):  
Gap Analysis ◽  
Heart Association ◽  
Measure Data ◽  
Quality Improvement Initiative ◽  
University Hospitals ◽  
Stroke Registry ◽  
National Quality ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
System Average

Target Stroke, a national quality improvement initiative of the American Heart Association /American Stroke Association (AHA/ASA) to improve the timeliness of administration of intravenous (IV) tissue plasminogen activator (tPA) to eligible stroke patients, was launched in 2010. The door-to-needle time goal is 60 minutes (mins) from hospital arrival. Earlier administration of IV t-PA is associated with greater functional recovery. Since 2009 University Hospitals Comprehensive Stroke and Cerebrovascular Center (UHCSCC) has meet quarterly with its 7 system community hospitals to share stroke core measure data, review clinical practice guidelines and address new system initiatives for the care of the stroke patient. The purpose of this project is to demonstrate how a comprehensive stroke center (CSC) can assist a primary stroke center (PSC) to improve their door to tPA treatment times. In 2010 to support the primary stroke centers, the UHCSCC developed standardized stroke education for nurses including an online course for tPA. In 2014 an additional online interactive module was created to assist nurses in programing the Alaris IV pump to improve their speed. In 2013 the quarterly system meetings started to include door to CT and door to tPA data with discussions about best practices and challenges. The AHA Target Stroke campaign recommendations and evidenced-based strategies were reviewed and a gap analysis at each hospital was completed to identify opportunities. Throughout 2012-2013 the stroke coordinator at UHCSCC led monthly conference calls with the community stroke coordinators. Since 2014 the stroke operations manager visits each community hospital monthly to work with the stroke coordinator and their teams reviewing TPA cases. Finally, a formal feedback took was developed and is sent to the PSC to provide patient outcomes and opportunities on all TPA cases that are transferred to the CSC. The AHA Get With The Guidelines stroke registry is used to monitor compliance. In 2012 the University Hospitals Health System average door to tPA in 60 mins was only 41%. January - June 2015, the system average has improved 86%. Community primary stroke centers benefit from the comprehensive stroke center interventions and support to improve door to tPA in 60 mins.

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