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Research ArticleDOI Number : 10.36811/ijcgh.2020.110007Article Views : 1Article Downloads : 0

Evaluation of association of relevant past history, symptoms, signs, complication profile and sero prevalence of HBV and HCV among the patients presenting with chronic liver disease and its complications: A Tertiary Care Hospital Based Study

Richmond Ronald Gomes1* and Akmat Ali2

1Associate Professor, Medicine, Ad-din Women’s Medical College Hospital, Dhaka, Bangladesh
2Associate Professor, Hepatology, Ad-din Women’s Medical College Hospital, Dhaka, Bangladesh

*Corresponding Author: Richmond Ronald Gomes, Associate Professor, Medicine, Ad-din Women’s Medical College Hospital, 2 Bara Maghbazar, Dhaka1217, Bangladesh, Tel: 8801819289499; Email: rrichi.dmc.k56@gmail.com 

Article Information

Aritcle Type: Research Article

Citation: Richmond Ronald Gomes, Akmat Ali. 2020. Evaluation of association of relevant past history, symptoms, signs, complication profile and sero prevalence of HBV and HCV among the patients presenting with chronic liver disease and its complications: A Tertiary Care Hospital Based Study. Int J Clin Gastro Hepato. 2: 09-18.

Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Copyright © 2020; Richmond Ronald Gomes

Publication history:

Received date: 17 August, 2020
Accepted date: 11 September, 2020
Published date: 14 September, 2020

Abstract

Background: Now-a-days chronic liver disease is one of the major health problems in the world. In developing countries, chronic liver disease due to hepatitis virus (like hepatitis B and hepatitis C virus) is increasing day by day. It is rapidly emerging as a major health problem. So the present study was conducted to document the hepatitis B and hepatitis C virus in patient with chronic liver disease by an easy and simple marker like HBsAg, Anti HBc (total) and Anti HCV in a tertiary hospital.

Methods: Serum samples were collected from 100 selected cases who were diagnosed as a case of chronic liver disease in medicine and gastroenterology department of DMCH. Study period was from April 01, 2016 to September 30, 2018. For detection of HBsAg, Anti HBc (total) and Anti HCV, Immunochromatographic test (ICT) was done in every case.

Results: Out of 100 cases, HBsAg seropositive with negative Anti HCV was found in 64% cases, Anti HCV positive with negative HBsAg was found in 16% cases, both HBsAg and anti HCV positive was found in 4% cases, both HBsAg and anti HCV negative was found in 16% cases. Among these cases, 74% were male and 26% were female. Here male: female was 3:1 and among them, 75% male was seropositive for either HBsAg or Anti HCV.

Conclusion: The high frequency of seropositivity in patients with chronic liver disease with male predominance is found in tertiary care settings. The number of Anti HCV seropositive patient indicates that it is an emerging health problem in our country.

Keywords: Chronic liver disease; HBsAg; Anti HCV; ICT

Introduction

Chronic liver disease is one of the common hepatobiliary problems worldwide. A major portion of the cases of chronic liver disease presents as a sequel of hepatotrophic viral infection specially hepatitis B and hepatitis C virus. Hepatitis B virus infects more than 350 million people worldwide and it is a leading cause of chronic hepatitis, cirrhosis and hepatocellular carcinoma [1]. On the other hand hepatitis C virus infects an estimated 170 million people worldwide and it represents a viral pandemic and mostly causes chronic infection leading to cirrhosis in 15-20% of those [2]. In Bangladesh the prevalence of chronic viral hepatitis is quite significant [3,4]. It has been observed that a large number of people in Bangladesh suffer from viral hepatitis every year. Around 10-15% of patients are treated for liver diseases including hepatitis and their sequelae in medical units in hospitals of Dhaka city [5-9]. Hepatitis B virus infection is the major cause of mortality and morbidity related to chronic liver disease and also hepatitis C virus is emerging as another major health problem [3-4]. The patients with chronic liver disease in our hospital usually come with overt clinical manifestations and complications. In our country vast majority of cases are non alcoholic post viral sequelae is the most important cause. Among the etiologically implicated hepatotrophic viruses, hepatitis B virus has been reported most important and hepatitis C virus related especially to chronic infection [9-12]. Clinically persistent presences of HBsAg and/or Anti- HCV are correlated with chronic liver disease [9-13]. Most of the patients of chronic liver disease are likely to be the carrier of these viruses and hence persistent viraemia resulting in positive HBsAg and/ or Anti-HCV so they are potential source of hepatitis B (HBV) and hepatitis C (HCV) virus infection for others [14-16]. This study yet not has been done in our hospitals settings. This study is therefore undertaken to show the pictures of two common and cost effective viral markers like HBsAg and Anti-HCV(for hepatitis B and hepatitis C virus infection respectively) in patients with chronic liver disease and their demographic profile, clinical presentation, complication profile and other related findings. The study will try to evaluate demographic profiles of those patients having post -viral (HBV and HCV) CLD in our settings.

Materials and Methods

This observational, descriptive, longitudinal study was carried out on Medicine units and department of Gastroenterology of Dhaka Medical College Hospital from April, 2016 to September 2018. Total 100 cases, age between 15 to 75 years, including known cases of chronic liver disease with or without complications were selected. Diagnosis was made by analysis of clinical, biochemical, endoscopy of upper GIT and USG of whole abdomen findings. Histopathological examination was done in some selected cases. Collected data’s were analyzed with computer software SPSS.

Inclusion criteria: All cases (including known cases) of chronic liver disease with or without complications will be selected. Diagnosis will be made by analysis of clinical, biochemical and imaging features including evidences of varices on upper GI endoscopy. Histopathological examination will be done in some selected cases. Initial criteria’s for selection of cases as chronic liver disease are:

• Age between 15 to 75 years, and

• Presence of stigmata of chronic liver disease( e.g. spider naevi, palmer erythema, gynaecomastia, testicular atrophy), and/or

• Cases having jaundice for more than 6 months, and/or

• Clinical and laboratory evidences of portal hypertension.

Exclusion criteria:

• Age < 15 years or > 75 years

• The patient with chronic liver disease with known etiology other than hepatotrophic virus (Wilson’s disease, drug induced, hemochromatosis, autoimmune hepatitis etc).

• The patients who will refuse to give consent

• The patient who will leave hospital before diagnosis

• Pregnant ladies

Following investigations will be done in all cases to support the diagnosis

• CBC, PBF

• LFT’s: S. bilirubin, , ALP, STP, S. Albumin, A:G, PT

• USG of Whole Abdomen

• Upper GIT endoscopy

• Tests for viral markers: HBsAg, Anti HBc (total), Anti- HCV.

• Alfa- Feto protein for suspected HCC

Results

A total number of 110 patients were screened and they were diagnosed as a case of chronic liver disease (CLD). Among them 10 were excluded from the study. Among the excluded cases, 4 were absconded, 2 were dead before satisfactory diagnosis, 3 refused to give consent and 1 was known case of Wilson’s disease. Total 100 cases were selected. Observational findings of this study are shown in different frequency tables and charts.

Discussion

In Bangladesh, Chronic parenchymal liver disease (CLD) is a common hepatobiliary problem. Chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infection are regarded as the most important cause of chronic liver disease in Bangladesh [3,6,7]. A substantial number of hospital admitted CLD patients are likely to be chronic carriers of HBV and HCV. A common serologic marker of HBV infection is HBsAg and HCV infection is Anti-HCV. After first identification of HBsAg by Blumberg et al [17], it has been widely used to identify chronic carriers of HBV. The HCV was discovered in 1989 and Anti-HCV antibodies were identified soon after the virus was discovered, and current iterations of these assays enable past exposure to HCV to be determined with high degree of accuracy [1,2,5]. Therefore, these patients constitute a major medical health hazards for medical personnel as well as for other patients by acting as a potential source of HBV and HCV infection. The present study was undertaken to find out the seroprevalence of HBsAg and Anti-HCV among the patients with CLD in DMCH with their demographic pattern, clinicopathological presentation, complication profile and the correlation of these features. I have screened 110 consecutive patients who were admitted in medicine and gastroenterology units of Dhaka Medical College Hospital. Among them, 10 were excluded from the study. Among the excluded cases, 4 were absconded, 2 were dead before satisfactory diagnosis, 3 refused to give consent and 1 was known case of Wilson’s disease. Total numbers of 100 cases were selected and ages of all were 15 years or more. Clinical history of the patients with their particulars (age, sex, occupation, socioeconomic condition, marital status (relevant past history) past H/O jaundice, hospitalization, hematemesis &melaena, altered or loss of consciousness, alcohol history, transfusion history, H/O injectable drug use were carefully noted. The diagnostic parameters like biochemical, serological, ultrasonographic and endoscopic study were available in 100 percent cases; in addition histopathological examination was available in 28% of cases. Although ideally all the cases should have been studied by biopsy, but different contraindications (huge ascites, prolonged PT), logistic and financial difficulties and patients refusal precluded histopathological study in all cases. However, strict attention to clinical and pathological details and other important investigations (like liver function tests including PT, USG of whole abdomen, endoscopy of upper GIT done in all cases) considerable compensated the lack of histopathological evidence. Among the 100 cases, in hospital settings, most of them are in decompensated stage or with complications which indicate compensated CLD are usually not come to our hospital for further management. Among the 100 cases, HBsAg seropositive with negative Anti-HCV in 64% cases, Anti-HCV positive with negative HBsAg in 16% cases, both HBsAg and Anti-HCV positive in 4% cases and both HBsAg and Anti-HCV negative in 16% cases (Table 1).

Table 1: Seroprevalence of HBsAg and Anti-HCV in patients with chronic liver disease (CLD) (n= 100).

Name of viral marker with status

 

 

Total

Percentage (%)

HBsAg positive but Anti-HCV negative

64

64

Anti HCV positive but HBsAg negative

16

16

Both HBsAg and Anti-HCV positive

4

4

Both HBsAg and Anti-HCV negative

16

16

So, still HBsAg seropositive group has higher prevalence among the patients with CLD and several number of Anti-HCV seropositive cases indicate that chronic liver disease as a result of HCV infection is not uncommon. Co-infection should be also considered in case of chronic liver disease. Different previous reports from Bangladesh showed a wide range (30-62.5%) of HbsAg seropositivity in CLD patients [8,18,19,20]. Naher Daulatun, Bishwas Jolly et al showed 65.9% HBsAg positive in patients of CLD in a hospital of Bangladesh which is almost similar to this study findings3. Khan M, Kiyosawa K, Yano M et al showed 24.1% seropositive for Anti-HCV in patients with CLD in Bangladesh which is almost similar to this study findings report [4] (16+8=24%). Chakravarti A, Verma V. Prevalence of hepatitis B and hepatitis C viral markers in patients with chronic liver disease: A study from Northern India showed HBV infection in 60.6% cases & it was detected by using all three markers. Among them, HBsAg was positive in 33.3% cases. Similar findings were reported by other workers but it was lower than this study. HCV infection was present in 25.75% patients with CLD which is similar to my study 16. 79.41% of total HCV infected cases showed co infection with HBV (past or present infection) [16]. Here co infection was detected by various markers but in this study we had done only one marker that might be the cause of having HBsAg with Anti-HCV positive in 4% cases. The high prevalence of HBsAg among the patients with CLD is not surprising if we consider that the HBsAg prevalence amongst the general population of Bangladesh which is between 7.8 to 8.6 percent12. But prevalence of CLD due to HCV infection is not less now a days [12]. High incidence of HbsAg seropositiviry in the patients with CLD ranging from 25 to 60% had been reported from Iraq [21], Greece [22], Italy [36], Africa [23] & India [24]. All of these countries have high HbsAg seroprevalence amongst the general population [22,24]. Such association however was rarely observed in patients with CLD in Australia [25] and Great Britain [26]. This is consistent with their very low (0.1-0.2%) HBsAgseroprevalence amongst general population. Another study was done in Myanmar and khin Pyone Ky, Myo Aye, et al showed Anti-HCV positive in 38.5% cases of cirrhosis, in 29.3% cases of HCC. Although general population showed 2.5% Anti HCV positive [22]. Regarding relevant past history (Table-2).

Table 2: Distribution of relevant past history among the different HbsAg and Anti-HCV serogroups in patients with CLD (n= 100).

Relevant past history

HbsAg positive but Anti-HCV negative

Anti- HCV positive but HbsAg negative

Both HbsAgand Anti-HCV positive

Both HbsAgand Anti-HCV negative

Total: n=100(%)

 

n=64(%)

n=16(%)

n=4(%)

n=16(%)

 

Jaundice

30(46.88%)

1(12.5%)

2(50%)

6(37.5%)

40

Haematemesis&melaena

8(12.5%)

0(0%)

2(50%)

2(12.5%)

12

Blood transfusion

6(9.38%)

6(37.5%)

2(50%)

0(0%)

14

Common syringe sharer

6(9.38%)

4(25%)

0(0%)

0(0%)

10

Surgery

4(6.25%)

0(0%)

0(0%)

0(0%)

4

Hospitalization

12(18.75%)

4(25%)

2(50%)

0(0%)

18

Abdominal or leg swelling

8(12.5%)

1(12.5%)

0(0%)

2(12.5%)

10

Unconsciousness

2(3.13%)

0(0%)

0(0%)

0(0%)

4

No history

12(18.75%)

1(12.5%)

0(0%)

0(0%)

20

I found that history of previous jaundice was present in 40% cases, history of previous hospitalization in 15% cases, history of blood transfusion in 14% cases among the patient with CLD. Among those, history of jaundice was less (12.5%0 and history of blood transfusion (37.5%) and I.V drug abuse (25%) were found more in positive Anti-HCV group. Almost all had history of using common blades for shaving which is not shown in this table. No relevant past history was available in 20% cases. Past history of jaundice was found in 40% cases in my study with little difference between HBsAg positive (46.88%), both positive group (50%) and both negative group (37.5%) but found less in positive Anti-HCV group (12.5%). The 40% incidence of past history of jaundice is higher than those reported by Islam (21.5%) [7] and Khan (20.7%) [8] but lower than those reported by Sobur (43.3%) [27], Chowdhury (36%) [28], Datta (25.5%) [29] and Parveen’s (43.5%) [30] studies. Arms Cruz et al [31] (1951) obtained history suggestive of hepatitis in 26% of 208 patients with CLD. In my study, among the CLD cases, past history of jaundice, injection and hospitalization were most common relevant past history. But in comparison to different serogroups, Anti-HCV positive group and both positive group had higher incidence of previous history of blood transfusion (37.5% and 50%), previous injections (25% and 0%), and HBsAg positive group and both positive group had higher history of hematemesis and melaena (12.5% and 50%). As a whole, 20% of patients gave no significant past history. Previously Chowdhury [28] and Parveen [30] have shown that history of previous injection, blood transfusion and hospitalization are positively correlated with HBsAg positivity among general population.An editorial showed that Anti-HCV positive in 24.8% injectable drug abusers, 12.5% in thalassemic patients, and 5.8% in non injectable drug abusers. TaherSelim Khan et al showed that the patients with CLD with Anti-HCV positive had history of blood transfusion, I.V drug abuse, needle prick, sharing common raz razor etc which is consistent with this study [15]. Islam [7] observed that evidenced that the absence of significant past history was mainly due to poor educational standard and intellectual level of the patients. However, they contended that some of these cases may have had anicteric hepatitis. Lack of parenteral (injection, blood transfusion, surgery) or sexual exposure in many of the HBsAg positive patients in this part of the world raise the possibilities that mosquitoes, bed bugs, cockroaches and contaminated needle pierce during nose and ear piercing or exposure at barber shop and contaminated tooth brush may be responsible for the transmission of HBV and HCV which is common in area endemic for the viruses [15,22,27,32,33]. It occurs especially in pre-adolescent children. Saliva and very small amount of blood on skin wound could be the major vehicle for horizontal transmission [27,32]. In the developed countries of North America, Western Europe and South America, Chronic alcoholism is the most important cause of cirrhosis and other CLD [19-1]. In Bangladesh, prevailing social, religious and economic factors dictate that alcoholism is not an important etiological factor for cirrhosis and other CLD.Various types of symptoms (Table- 3) in different serogroups of patients with CLD. Most common symptoms were abdominal swelling (58%), altered consciousness (28%), upper abdominal discomfort (26%), hematemesis and melaena (28%), passage of high colored urine (24%), yellow coloration of eyes (24%), scanty micturition (16%), and loss of libido (14%).

Table 3: Comparison of symptoms in patients with CLD (n=100).

 

HbsAg positive but Anti-HCV negative

Anti- HCV positive but HbsAg negative

Both HbsAg and Anti- HCV

Both HbsAg and Anti- HCV

Total: n= 100(%)

 Symptoms

 n=64(%)

 n=16(%)

Positive n=4(%)

Negative n=16(%)

 

Weakness

4(6.25%)

2(12.5%)

0(0)%

0(0)%

6

Anorexia

8(12.5%)

0(0)%

0(0)%

0(0)%

8

Yellow coloration

14(21.88%)

4(25%)

2(50%)

4(25%)

24

of eyes

 

 

 

 

 

Nausea or vomiting

6(9.38%)

2(12.5%)

2(50%)

0(0)%

10

Upper abdominal discomfort

18(28.13%)

4(25%)

2(50%)

2(12.5%)

26

Dull abdominal pain

6(9.38%)

0(0)%

0(0)%

0(0)%

6

Abdominal lump

4(6.25%)

0(0)%

0(0)%

0(0)%

4

Abdominal swelling

30(46.88%)

10(62.5%)

4(100%)

14(87.5%)

58

Ankle swelling

12(18.75%)

4(25%)

0(0)%

2(12.5%)

18

Altered consciousness

18(21.88%)

8(50%)

0(0)%

2(12.5%)

28

Haematemesis and  melaena

16(25%)

4(25%)

2(50%)

0(0)%

22

Here the complaints of abdominal swelling was the most common presenting symptoms and among those which was found more in both positive (100%) and both negative (87.5%) groups of patients. The reason behind it most of the cases were decompensated. Examination of the patient revealed (Table-4) splenomegaly on 78% cases; ascites in 58% cases, which comparable to the reports of Parveen’s study [30] and it was in 64.28% of cases. In Islam [7] (80.5%), Chowdhury [28] (87%), Datta [29] (87.5%) and Armus- Cruz’s [31] (74%) studies, it was higher than my study.Anemia was detected in 40% cases, clinical jaundice in 42% cases. The reported incidence of clinical jaundice in cirrhotic patients in Bangladesh ranges from 20.1 to 68.7% [6-8,27-29,34]. Other signs like testicular atrophy (32%) and gynaecomastia (27%) (In male), spider naevi (10%) were found less frequently. The incidence of these peripheral classical stigmata of cirrhosis was consistent with the findings of Sobur [27], Chowdhury [28], Parveen [35], Rahman [30], Rahman MA’s [34] et al studies. However, much lower incidence of these classical clinical features was also reported in Sobur [27] study. Reduced sexual body hairs (12%), gynaecomastia (27%) and testicular atrophy (32%) in male and breast atrophy (20%) in females, manifests the degree of endocrine dysfunction and are comparable with other studies [28-30]. Huge ascites (a feature of hepatic decompensation and portal hypertension) was present in 14% cases (Table-4) and was associated with pleural effusion in 4% cases in this study. The incidence of huge ascites was below and pleural effusion was consistent with Chowdhury [28] (32% and 6%) and Parveen [30] studies (34.6% and 3.7%). Splenomegaly and hepatomegaly were present in 78% and 22% of the cases respectively in this series, among them 18% had both hepatosplenomegaly. In Datta’s [29] studies, it was in 53% and in 50% respectively and in Parveen’s [30] studies it was in 55% and in 15% respectively and both hepatosplenomegaly in 7.5% cases. Hepatic encephalopathy (Table-5) was found in 20% of cases, which clearly differs from the findings of Chowdhury [28] (4103%) and Parveen [30] (7.5%) studies. In Bangladesh, reported incidence of encephalopathy varies from 7-31% [6]. A few differences of physical signs were observed in patients of different serogroups. I found that jaundice (50%) and anemia (43.7%) were more frequent in HBsAg seropositive group, less frequent in Anti-HCV (37.5% & 25%) seropositive group and both seronegative group. Ascites and splenomegaly were found more in Anti-HCV (87.5% and 75%) seropositive and both seronegative group less in HBsAg seropositive group (47%, 75%) and both seropositive group (46.88% and 50%). The seronegative patients had higher incidence of evidence of portal hypertension. Study of complication profile (Table-5) showed that 20% of the patient had hepatic encephalopathy, 36% had hemorrhagic manifestation and 28% had refractory ascites. HCC was found in 6% of patients. The magnitude of complication profile is lower than that of Chowdhury [28]. study but consistent with previous other studies [8,29,30]. Chowdhury [28], Khan and Islam (1985) [36] found hepatic encephalopathy in 37% and in 31% cases respectively which is a bit higher than present study (30%) but much higher than Parveen 30 (7.5%) study. 6% cases had concomitant HCC which is lower than the previous study of Chowdhury [28] (9%) and Khan and Islam (1985) [36] (9.3%) but much lower than Irin’s study (32.5%). SBP was found in 2% cases which is consistent with previous studies by Chowdhury 28 (2%) and Parveen [30] (2.5%). Among different serogroups, the complications of CLD were found more in seropositive groups. But hepatorenal syndrome and refractory ascites were found more in both seronegative group (12.5% and 25%).

Table 4: Comparison of signs in patients with CLD (n= 100).

 

Signs

HbsAg positive but Anti- HCV

Negative

n=64(%)

Anti- HCV positive but HbsAgnegative

n=16(%)

Both HbsAg and Anti- HCV

positive

n=4(%)

Both HbsAgand Anti-HCV negative

 

n=16(%)

Total: n= 100(%)

Hepatic facies

8(12.5%)

8(50%)

2(50%)

6(37.5%)

26

Anemia

28(43.75%)

4(25%)

2(50%)

6(37.5%)

40

Jaundice

32(50%)

6(37.5%)

0(0%)

4(25%)

42

Fever

4(6.25%)

0(0%)

0(0%)

0(0%)

4

Leuconychia

2(3.13%)

0(0%)

0(0%)

0(0%)

2

Spider naevi

8(12.5%)

0(0%)

0(0%)

2(12.5%)

10

Loss of body hair

8(12.5%)

4(25%)

0(0%)

0(0%)

12

Gynaecomastia

12(25%)

4(25%)

0(0%)

4(25%)

220

Testicular atrophy

14(29.12%)

4(25%)

0(0%)

4(25%)

24

Ascites

30(46.88%)

14(87.5%)

2(50%)

12(75%)

58

Ankle edema

14(21.88%)

0(0%)

0(0%)

2(12.5%)

16

Hepatomegaly

16(25%)

2(12.5%)

0(0%)

4(25%)

22

Splenomegaly

48(75%)

16(100%)

2(50%)

12(75%)

78

Hepatosplenomegaly

12(18.75%)

2(12.5%)

0(0%)

4(25%)

18

Hepatic encephalopathy

16(25%)

8(50%)

0(0%)

2(12.5%)

26

 

Table 5: Comparison of complication profile in patient with CLD (N=100).

 Complications

HbsAg positive but Anti-HCV negative

Anti- HCV positive but HbsAg negative

Both HbsAgand Anti-HCV positive

Both HbsAg and Anti- HCV

 

 

n= 64(%)

n= 16(%)

n= 4(%)

Negative n= 16(%)

Total n= 100(%)

Haematemesis&melaena

26(40.63%)

6(37.5%)

2(12.5%)

2(12.5%)

36

Hepatic encephalopathy

10(15.63%)

8(50%)

0(0%)

2(12.5%)

20

Hepatorenalsyndrome

4(6.25%)

0(0%)

0(0%)

4(25%)

8

SBP

2(3.13%)

0(0%)

0(0%)

0(0%)

2

Refractory ascites

16(25%)

2(12.5%)

2(12.5%)

8(50%)

28

HCC

6(9.38%)

0(0%)

0(0%)

0(0%)

6

Conclusion

Chronic liver disease (CLD) is common in tertiary care hospital setting. Hepatitis B (HBV) and Hepatitis C (HCV) virus are important causes of chronic liver disease (CLD). Hepatitis C virus is an emerging problem. In tertiary care hospital most of the patients of chronic liver disease are in decompensated stage with various complications. HBsAg and Anti-HCV are two important sensitive and cost-effective markers for detection of Hepatitis B and Hepatitis C virus infection. So protection against Hepatitis B and Hepatitis C virus infection should be an important strategy for preventing incidence of chronic liver disease in community.

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