Publications by authors named "Sharon H Gnagi"

17 Publications

  • Page 1 of 1

Pediatric Unilateral Vocal Fold Immobility.

Pediatr Ann 2021 Jul 1;50(7):e286-e291. Epub 2021 Jul 1.

Vocal fold immobility in children can affect breathing, swallowing, and speech function. Although sometimes idiopathic, it is often caused by injury to the recurrent laryngeal nerve during cardiac surgery. A detailed history and physical examination can identify risk factors, which affect the rate of resolution and overall prognosis. Fiberoptic laryngoscopy can be used to confirm the diagnosis and evaluate laryngeal anatomy. Many treatment options exist to improve function and quality of life, including vocal fold injection and laryngeal innervation. .
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http://dx.doi.org/10.3928/19382359-20210628-01DOI Listing
July 2021

Thyroid Nodule/Differentiated Thyroid Carcinoma in the Pediatric Population.

Pediatr Ann 2021 Jul 1;50(7):e282-e285. Epub 2021 Jul 1.

Symptoms of thyroid nodules and differentiated thyroid cancer include those of hypo- or hyperthyroidism, voice changes, difficulty breathing when supine, globus sensation, dysphagia, and cervical adenopathy. Surgery has been the first-line mainstay treatment option for large thyroid nodules and thyroid carcinomas. This article highlights thyroid carcinoma in the pediatric population and reviews the current testing and management options. .
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http://dx.doi.org/10.3928/19382359-20210621-01DOI Listing
July 2021

A quality improvement project for managing hypocalcemia after pediatric total thyroidectomy.

J Pediatr Endocrinol Metab 2020 Nov;33(11):1443-1448

Phoenix Children's Hospital, Division of Endocrinology and Diabetes, Phoenix, AZ, USA.

Objectives Hypocalcemia following total thyroidectomy (TT) is relatively common. It may result in significant morbidity, prolonged hospital stay, and increased costs. Treatment with intravenous (IV) calcium gluconate may also carry significant risks. In pediatrics, management consensus guidelines are lacking. Methods At Phoenix Children's Hospital, a team of pediatric endocrinologists, surgeons and otolaryngologists developed a clinical pathway for patients undergoing TT. It was a Quality Improvement (QI) project with the primary aim of decreasing IV calcium gluconate use from a baseline of 68% to less than 40% over 15 months. Secondary aims included reducing hypocalcemia and length of hospitalization. Interventions included sending weekly pathway reminder emails, starting pre-operative calcium, and pathway implementation into the electronic health record. Results Twenty-seven patients underwent TT over 15 months. IV calcium gluconate use dropped to 48%. Hypocalcemia and length of hospitalization were 96% and 52.7 h (range 21.1-115.7) respectively. Pathway adherence improved after targeted interventions. Eleven (73%) of the 15 patients whose post-operative parathyroid hormone (PTH) nadir was below 15 pg/mL required IV calcium gluconate vs. two (17%) out of 12 with levels above this threshold. Conclusions Standardizing care allowed for objective outcome analysis. We learned that post-operative serum PTH level was the main risk factor for requiring IV calcium gluconate. Implementing the pathway as a QI project allows for revisions based on outcomes, ultimately resulting in a pathway that best utilizes our infrastructure to optimize care. Other pediatric institutions may face similar challenges and can potentially learn from our experience.
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http://dx.doi.org/10.1515/jpem-2020-0376DOI Listing
November 2020

Pharyngeal Flap Versus Sphincter Pharyngoplasty for Velopharyngeal Insufficiency: A Review of the 2014 and 2015 American College of Surgeons National Surgical Quality Improvement Project-Pediatrics Data.

J Craniofac Surg 2019 Mar/Apr;30(2):554-556

Department of Otolaryngology, Head and Neck Surgery, Medical University of South Carolina, Charleston, SC.

The authors sought to compare hospital utilization and complications in patients undergoing pharyngeal flap (PF) or sphincter pharyngoplasty (SP) for velopharyngeal insufficiency (VPI). A retrospective analysis of the 2014 and 2015 American College of Surgeons National Surgical Quality Improvement Project-Pediatrics (ACS NSQIP-P) was performed. Current procedural terminology codes were used to identify children undergoing PF (42225, 42226) and SP (42950) for VPI (International Classification of Diseases version 9: 478.29, 528.9, or 750.29). Four hundred forty-six patients were treated for VPI with either PF (n = 250) or SP (n = 196). The groups were demographically similar in age, gender, race, and preoperative comorbidity. Pharyngeal flap was performed less often as an outpatient procedure than SP (96/250 [38.4%] vs 130/196 [66.3%], P < 0.0001) and had a longer total length of hospital stay (mean 1.76 ± 1.29 vs 0.98 ± 0.91 days, P < 0.0001). No difference in total complications (10/250 [4.0%] vs 3/196 [1.5%], P = 0.124) was identified. The reduction in hospital resource utilization (fewer admissions, shorter length of stay) is notable. No difference in complications was identified between the 2 procedures.
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http://dx.doi.org/10.1097/SCS.0000000000005164DOI Listing
August 2019

Pyridostigmine for the Reversal of Severe Adverse Reactions to Botulinum Toxin in Children.

J Pediatr 2018 03 22;194:241-243. Epub 2017 Dec 22.

Department of Otolaryngology-Head and Neck Surgery, Division of Pediatric Otolaryngology, Medical University of South Carolina, Charleston, SC; Department of Otolaryngology-Head and Neck Surgery, Evelyn Trammell Institute for Voice and Swallowing, Medical University of South Carolina, Charleston, SC.

Therapeutic botulinum toxin injections are commonly performed in pediatric otolaryngology. Aerodigestive complications from botulinum toxin injections, although rare, may be serious. Oral pyridostigmine is effective in the symptomatic treatment of these complications. We report 2 cases of aerodigestive complications arising from injection of botulinum toxin that were successfully treated with pyridostigmine.
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http://dx.doi.org/10.1016/j.jpeds.2017.11.013DOI Listing
March 2018

Blood transfusion in children with sickle cell disease undergoing tonsillectomy.

Int J Pediatr Otorhinolaryngol 2017 Dec 10;103:117-120. Epub 2017 Oct 10.

Department of Otolaryngology Head & Neck Surgery, Medical University of South Carolina, Charleston, SC, USA.

Introduction: Tonsillectomy is the second most common surgery in children with sickle cell disease. These children are at an increased risk of perioperative complications due to vaso-occlusive events. Although controversial, preoperative blood transfusions are sometimes given in an effort to prevent such complications. The purpose of this study is to analyze trends in the use of blood transfusion for management of children with sickle cell disease (SCD) undergoing tonsillectomy in a national database.

Methods: Patients in the 1997-2012 KID with a primary procedure matching the ICD-9 procedure code for tonsillectomy (28.2-28.3) and diagnosis code for SCD (282.60-282.69) were examined. Patients were split into groups by blood transfusion status and compared across variables including complication rate, length of stay (LOS), and hospital charges. Statistical analysis included chi-square test for trend, Mann-Whitney U test, and independent t-test.

Results: 1133 patients with SCD underwent tonsillectomy. There was a strong positive correlation between increasing chronologic year and the proportion of patients receiving blood transfusions, 47 (30.1%) in 1997 to 78 (42.5%) in 2012 (r = 0.94, p = 0.005). During this period, there was no significant change in the rate of complications (r = -0.1, p = 0.87). Overall, patients receiving blood transfusion had a longer mean LOS (3.1 ± 2.4 days vs. 2.5 ± 2.2 days, p < 0.005) and higher mean charge ($17,318 ± 13,191 vs. $13,532 ± 12,124, p < 0.005) compared to patients who did not receive blood transfusion. The rate of complications in the transfusion group, 18 of 352(5.1%), was not significantly different (p = 0.48) from the group without transfusion, 40 of 626 (6.4%).

Conclusions: From 1997 to 2012, there was a significant increase in the proportion of patients with SCD receiving perioperative blood transfusions for tonsillectomy. While the frequency of transfusion rose, those who received a transfusion had similar complication rates with increased charges and length of hospital stays compared to those who did not receive a transfusion.
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http://dx.doi.org/10.1016/j.ijporl.2017.10.013DOI Listing
December 2017

Sarcoidosis Presenting as Bilateral Vocal Fold Immobility.

J Voice 2018 May 3;32(3):359-362. Epub 2017 Jul 3.

Head and Neck Regeneration Program, Center for Regenerative Medicine, Mayo Clinic, Phoenix, Arizona; Department of Otorhinolaryngology, Mayo Clinic Arizona, Phoenix, Arizona. Electronic address:

Bilateral true vocal fold paralysis is rarely attributable to inflammatory diseases. Sarcoidosis is a rare but important etiology of bilateral true vocal fold paralysis by compressive lymphadenopathy, granulomatous infiltration, and neural involvement. We describe the first reported case of sarcoidosis presenting as bilateral vocal fold immobility caused by direct fixation by granulomatous infiltration severe enough to necessitate tracheostomy insertion. In addition, we discuss the presentation, the pathophysiology, and the treatment of this disease with a review of the literature of previously reported cases of sarcoidosis-related vocal fold immobility. Sarcoidosis should therefore be an important consideration for the otolaryngologist's differential diagnosis of true vocal fold immobility.
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http://dx.doi.org/10.1016/j.jvoice.2017.05.017DOI Listing
May 2018

Facial Nerve Meningioma: A Cause of Pediatric Facial Weakness.

Otol Neurotol 2017 03;38(3):e8-e12

*Department of Otorhinolaryngology, Mayo Clinic †Department of Pathology and Laboratory Medicine, Phoenix Children's Hospital ‡Department of Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona.

Objective: To present an unusual case of a temporal bone meningioma with intrafascicular spread throughout the temporal facial nerve from cerebellopontine angle (CPA) to stylomastoid foramen.

Patient: Four-year-old female with progressive facial weakness and normal hearing.

Main Outcome Measure: Clinical, radiological, and histopathological findings of temporal bone meningiomas.

Results: A patient presented with progressive facial weakness and normal hearing. Imaging demonstrated a mass within the left internal auditory canal radiologically consistent with a schwannoma. Asymmetric enlargement with enhancement of the left facial nerve from CPA to the stylomastoid foramen suggested facial schwannoma. At surgery, gross tumor was noted in the internal auditory canal, the fallopian canal seemed expanded and the facial nerve was enlarged and had an irregular contour. Resection of the facial nerve from the CPA to just proximal to its exit at the stylomastoid foramen was necessary to achieve negative margins. Cable grafting was performed. The histopathologic diagnosis was transitional meningioma with intraneural growth throughout the length of the resected facial nerve segment.

Conclusion: Meningiomas involving the temporal bone are exceedingly rare. We report a rare case of a child presenting with progressive facial weakness due to a presumed facial schwannoma spreading along the facial nerve throughout its intratemporal course that at surgery was found to be an intrafascicular CN VII meningioma.
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http://dx.doi.org/10.1097/MAO.0000000000001293DOI Listing
March 2017

Beyond dilation: current concepts in endoscopic airway stenting and reconstruction.

Curr Opin Otolaryngol Head Neck Surg 2016 Dec;24(6):516-521

Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery Medical University of South Carolina, Charleston, South Carolina, USA.

Purpose Of Review: To discuss current modalities of endoscopic airway management beyond balloon dilation therapy.

Recent Findings: Advances continue to be made through technology and bioengineering with exciting potential in the pediatric airway. Smaller robots and instrumentation allow increased endoscopic surgical success. Biodegradable stents and bioengineered grafts are on the horizon for use in airway surgery. Dysphonia following airway reconstruction is of increasing recognition with new endoscopic treatments being performed. Supraglottoplasty is further recognized as a treatment for obstructive sleep apnea for laryngomalacia diagnosed on sleep endoscopy. Interarytenoid injection may be beneficial in the normal larynx for aspiration and dysphagia as well as diagnosing and treating type I laryngeal clefts.

Summary: Endoscopic airway surgery continues to be a popular and effective method of treating the pediatric airway. Technological advances such as in robotics may have an increasing role in the future of endoscopic airway surgery in children. Bioengineered airway adjuncts including biodegradable airway stents look to be promising in the future treatment of airway stenosis.
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http://dx.doi.org/10.1097/MOO.0000000000000310DOI Listing
December 2016

Human Papillomavirus Vaccination Counseling in Pediatric Training: Are We Discussing Otolaryngology-Related Manifestations?

Otolaryngol Head Neck Surg 2016 07 29;155(1):87-93. Epub 2016 Mar 29.

Department of Otolaryngology, Mayo Clinic Arizona, Phoenix, Arizona, USA.

Objective: Demonstrate the need for increased education regarding otolaryngology-related manifestations of human papillomavirus (HPV). Highlight a need to incorporate otolaryngology-related manifestations of HPV in vaccine counseling.

Study Design: Survey.

Setting: Tertiary care academic children's hospital.

Subjects: Pediatric residents, fellows, and staff.

Methods: An online survey was made available regarding HPV education and vaccination.

Results: Participants (N = 348) initiated the survey representing 28.4%, 25.6%, and 19.0% postgraduate year 1, 2, and 3 residents, respectively, as well as 17.5% chief residents/fellows and 9.5% attendings. Participants rated their prior education as none or fair regarding recurrent respiratory papillomatosis (63.8%) and oropharyngeal squamous cell carcinoma (68.3%). In contrast, 60.6% and 70.9% rated their education on genital warts and cervical cancer correspondingly as good or excellent. When asked what was routinely discussed during HPV vaccine counseling, 63.3% reported "never" discussing recurrent respiratory papillomatosis and 52.9% "never" discussing oropharyngeal squamous cell carcinoma. A range from 92.7% to 95.5% responded that there was a need for increased education regarding HPV and its role in recurrent respiratory papillomatosis and oropharyngeal squamous cell carcinoma.

Conclusions: Increased education about HPV and its otolaryngology-related manifestations should be undertaken to increase provider, patient, and parent awareness of recurrent respiratory papillomatosis and oropharyngeal squamous cell carcinoma. We propose that discussing the risks of otolaryngology-related disease be routinely included in HPV vaccination counseling.
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http://dx.doi.org/10.1177/0194599816639932DOI Listing
July 2016

Management of rhinosinusitis during pregnancy: systematic review and expert panel recommendations.

Rhinology 2016 06;54(2):99-104

Royal National Throat, Nose and Ear Hospital, University College London Hospitals, London, United Kingdom.

Background: Management of rhinosinusitis during pregnancy requires special considerations.

Objectives: 1. Conduct a systematic literature review for acute and chronic rhinosinusitis (CRS) management during pregnancy. 2. Make evidence-based recommendations.

Methods: The systematic review was conducted using MEDLINE and EMBASE databases and relevant search terms. Title, abstract and full manuscript review were conducted by two authors independently. A multispecialty panel with expertise in management of Rhinological disorders, Allergy-Immunology, and Obstetrics-Gynecology was invited to review the systematic review. Recommendations were sought on use of following for CRS management during pregnancy: oral corticosteroids; antibiotics; leukotrienes; topical corticosteroid spray/irrigations/drops; aspirin desensitization; elective surgery for CRS with polyps prior to planned pregnancy; vaginal birth versus planned Caesarian for skull base erosions/ prior CSF rhinorrhea.

Results: Eighty-eight manuscripts underwent full review after screening 3052 abstracts. No relevant level 1, 2, or 3 studies were found. Expert panel recommendations for rhinosinusitis management during pregnancy included continuing nasal corticosteroid sprays for CRS maintenance, using pregnancy-safe antibiotics for acute rhinosinusitis and CRS exacerbations, and discontinuing aspirin desensitization for aspirin exacerbated respiratory disease. The manuscript presents detailed recommendations.

Conclusions: The lack of evidence pertinent to managing rhinosinusitis during pregnancy warrants future trials. Expert recommendations constitute the current best available evidence.
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http://dx.doi.org/10.4193/Rhino15.228DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5797655PMC
June 2016

Idiopathic Subglottic and Tracheal Stenosis: A Survey of the Patient Experience.

Ann Otol Rhinol Laryngol 2015 Sep 24;124(9):734-9. Epub 2015 Apr 24.

Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA

Objectives: To report and compare patients' experiences with acquired subglottic stenosis (AS) versus idiopathic subglottic and tracheal stenosis (ISTS).

Methods: A survey was made available to patients with AS and ISTS. Results were analyzed for inter- and intragroup differences using a 2-tailed t test.

Results: The study included 160 survey participants (AS n = 28; ISTS n = 132), with a predominance of female participants (82% AS, 98% ISTS). Acid reflux was the most prevalent comorbidity across groups (42%-43%). A significant difference in time to diagnosis was found between groups, with 32% of AS patients diagnosed within 3 months of symptom onset, compared to 2% with ISTS. A diagnosis delay greater than 18 months occurred for 58% of ISTS patients. There was no difference in treatment approach, with the most common treatment being balloon dilation, followed by laser dilation. Tracheal resection was performed in 36% of patients in both groups. Patient satisfaction with surgical outcomes was significantly higher after tracheal resection (76%) compared to other treatment modalities (39%).

Conclusions: ISTS remains a diagnostic challenge as highlighted by the delay in diagnosis compared to AS. There appears to be no historical or symptomatic factors specific to ISTS. Additionally, patients report increased satisfaction and symptom resolution after tracheal resection.
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http://dx.doi.org/10.1177/0003489415582255DOI Listing
September 2015

Analysis of Intraoperative Radiographic Electrode Placement During Cochlear Implantation.

Otol Neurotol 2015 Jul;36(6):1045-7

Department of Otolaryngology, Mayo Clinic Arizona, Phoenix, Arizona, U.S.A.

Objective: To investigate the clinical value of intraoperative plain radiographs in determining correct placement of cochlear implants.

Patients: All cochlear implant insertions over a 10-year period by a single surgeon.

Interventions: Cochlear implantation with intraoperative imaging.

Main Outcome Measure: Whether intraoperative imaging affects clinical/surgical management.

Results: A consecutive retrospective review of 207 cochlear implantations performed in 187 patients was performed. All implants performed had intraoperative plain film imaging. Etiology of hearing loss, surgical variations, gender, age, and implant type did not affect intraoperative imaging. Four cases were identified where variations in intraoperative imaging interpreted by the surgeon warranted further discussion. In one patient, the intraoperative x-ray interpretation missed an incorrectly placed electrode. Postoperative CT scan confirmed implant electrode within the superior semicircular canal. In three patients, intraoperative x-ray results aided management by confirming surgical findings; however, no subsequent clinical or surgical alterations were made based on imaging. One of these three patients experienced a noticeable function decline postoperatively that correlated with altered positioning of the cochlear implant on intraoperative radiographs. In all surgeries, no changes were made to the electrode placement based on the intraoperative radiographs.

Conclusion: Intraoperative plain film imaging during cochlear implantation, although commonly employed, does not typically affect clinical management. For select cases, imaging may continue to be useful based on the surgeon's discretion and intraoperative findings for confirmatory purposes.
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http://dx.doi.org/10.1097/MAO.0000000000000761DOI Listing
July 2015

Acute contained ruptured aortic aneurysm presenting as left vocal fold immobility.

Case Rep Otolaryngol 2015 11;2015:219090. Epub 2015 Jan 11.

Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA.

Objective. To recognize intrathoracic abnormalities, including expansion or rupture of aortic aneurysms, as a source of acute onset vocal fold immobility. Methods. A case report and review of the literature. Results. An 85-year-old female with prior history of an aortic aneurysm presented to a tertiary care facility with sudden onset hoarseness. On laryngoscopy, the left vocal fold was immobile in the paramedian position. A CT scan obtained that day revealed a new, large hematoma surrounding the upper descending aortic stent graft consistent with an acute contained ruptured aortic aneurysm. She was referred to the emergency department for evaluation and treatment by vascular surgery. She was counseled regarding surgical options and ultimately decided not to pursue further treatment. Her vocal fold immobility was subsequently treated via office-based injection medialization two weeks after presentation and again 5 months after the initial injection which dramatically improved her voice. Follow-up CT scan at 8 months demonstrated a reduction of the hematoma. The left vocal cord remains immobile to date. Conclusion. Ortner's syndrome, or cardiovocal syndrome, is hoarseness secondary to left recurrent laryngeal nerve palsy caused by cardiovascular pathology. It is a rare condition and, while typically presenting gradually, may also present with acute symptomatology.
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http://dx.doi.org/10.1155/2015/219090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4306210PMC
February 2015

Adult laryngeal rhabdomyoma with extralaryngeal extension: surgical excision and reconstruction with aortic homograft.

Otolaryngol Head Neck Surg 2014 Mar 23;150(3):501-2. Epub 2013 Dec 23.

Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Phoenix, Arizona, USA.

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http://dx.doi.org/10.1177/0194599813516748DOI Listing
March 2014

Hyalinizing trabecular tumor masquerading as papillary thyroid carcinoma on fine-needle aspiration.

ORL J Otorhinolaryngol Relat Spec 2013 2;75(6):309-13. Epub 2013 Oct 2.

Department of Otolaryngology, Head and Neck Surgery, Mayo Clinic Arizona, Phoenix, Ariz., USA.

Background/aims: Hyalinizing trabecular tumors are rare neoplasms of the thyroid gland often mistaken for thyroid carcinoma on fine-needle aspiration. We review the distinguishing characteristics of hyalinizing trabecular tumors and their management.

Methods: We present the case of a patient diagnosed with papillary thyroid carcinoma on fine-needle aspiration as well as a review of the literature.

Results: Intraoperative findings were felt to be inconsistent with papillary thyroid carcinoma and only a thyroid lobectomy was performed pending the results from pathologic evaluation, which confirmed a benign process and a diagnosis of hyalinizing trabecular tumor. Due to the diagnostic difficulty in distinguishing hyalinizing trabecular tumors from thyroid carcinomas on fine-needle aspiration, many patients receive overtreatment for what is primarily a benign disease.

Conclusions: Recognition of hyalinizing trabecular tumors as a possible benign etiology of a thyroid mass can facilitate appropriate management.
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http://dx.doi.org/10.1159/000355291DOI Listing
October 2014

Nasal obstruction in newborns.

Pediatr Clin North Am 2013 Aug 3;60(4):903-22. Epub 2013 Jul 3.

Department of Otolaryngology, Mayo Clinic Arizona, Phoenix, AZ 85054, USA.

Nasal obstruction is a serious clinical scenario in the newborn infant with a large differential diagnosis. This article reviews the etiologies of nasal obstruction to aid the pediatrician in prompt evaluation, diagnosis, and treatment.
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http://dx.doi.org/10.1016/j.pcl.2013.04.007DOI Listing
August 2013
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