The Preparticipation Evaluation
Author: Clayton F. Holmes, EdD, PT, ATC, Assistant Professor, University of Central Arkansas, Department of Physical Therapy, Little Rock, Ark.
Peer Reviewers: Brian Hardin, MD, Director of Adolescent Medicine, Adolescent Medicine Section, Arkansas Children’s Hospital, Little Rock, Ark; Stephen B. Gunther, MD, Assistant Professor of Clinical Orthopaedic Surgery, UCSF Department of Orthopaedic Surgery, San Francisco, Calif; and Robert C. Schenck, Jr., MD, Professor and Division Chief, Sports Medicine Section, University of New Mexico Health Science Center, Albuquerque, NM.
Editor’s Note—Each year, between 17 and 25 million adolescents engage in some type of organized sports activity.1 This includes more than 6 million high school athletes at approximately 20,000 high schools.2 In the population of high school athletes alone, more than 2 million injuries occur each year. This necessitates approximately 500,000 doctor visits and 30,000 hospitalizations.3 In terms of scholastic sports, football and basketball (male and female) are the most popular. Despite these mind boggling statistics, there remains some question as to the value of a preparticipation examination.4 This is true despite the fact that the majority of the United States legally require preparticipation evaluations (PPEs) for participation in all junior and senior high school sports.1
The controversy regarding PPEs centers around what the stated goals are for the evaluation. In other words, if one wishes to discuss the merit of the PPE, then one must first determine the major goals of the endeavor.4 In fact, when the stated goal of the PPE is only to identify life-threatening predispositions to activity, the PPE is seen of little value in some authors.5 Many authors argue that the small number of individuals with life-threatening problems identified and helped by the PPE means that more than 4000 evaluations are required to identify one individual. After all, the vast majority of these athletes are at low risk for conditions (i.e., sudden death due to coronary abnormalities such as that seen with hypertrophic cardiomyopathy).4,5 In addition, it stands to reason that most of these athletes are already active outside of their participation in organized athletics. In other words, these individuals are already active and it is rational, if not "safe," to assume that symptoms such as syncope or exertional dizziness would have occurred prior to entry into organized athletics. If activity in general has not initiated these symptoms, then it stands to reason activity in organized sports is not going to either.
These arguments could, however, be made for many preventive measures. One must conclude that this thought process is contributory to the continued de-emphasis on prevention in general, across the entire health care industry in the United States.
However, when the stated goals include objectives other than just preclusion due to a life-threatening event, then the value of the PPE becomes clear. McKeag identified the following 11 reasons to perform the preseason screen: 1) determination of general health of the athlete; 2) disclosure of defects that may limit participation; 3) detect conditions that may predispose the athlete to injury; 4) determine optimal level of performance; 5) classify the athlete according to individual qualifications; 6) fulfillment of legal requirements for a specific athletic program (e.g., state regulations that require high schools to perform a PPE on every athlete); 7) evaluation of the level of maturation of younger athletics; 8) evaluation of fitness and performance for possible improvement prior to participation; 9) provision of opportunities for students to compete with specific health issues that may preclude a blanket approval (e.g., an athlete with diabetes can still participate but needs access to medical services and may have special precautions); 10) provisions of opportunity to counsel youths regarding personal health issues (e.g., counseling concerning the use of drugs); and 11) entry of the athlete into the local sports medicine environment thereby establishing a doctor-patient relationship.6
Perhaps one of the most controversial goals of the PPE is the evaluation of the maturation level of the athlete.7 This involves the use of the Tanner staging method. This is a method whereby the physician determines the maturational age of the athlete based on an inventory of secondary sex characteristics. While maturational age is not commonly used as a criteria to rule someone out of participation, it could be used to match the individual with the sport and should be a major consideration when contact sports such as football, wrestling, or basketball are concerned.7
It is also possible that the preseason screen is the only time the athlete has access to a physician. Questions of a personal nature that the athlete is not likely to discuss with other adults such as coaches, may be addressed at that time. For example, the athlete may feel comfortable discussing the use of anabolic steroids with the physician when he or she would not have this same discussion with officials from the scholastic environment. It is important to note that the preseason screen is an opportunity for the physician to engage in this type of conversation with both the athlete and his or her parents when necessary. One specific way to facilitate this conversation will be described later, when discussing history. Athletes should certainly be asked, at a minimum, if he or she wishes to participate in the chosen sport. In other words, who chose the sport for the athlete? This concern may go hand in hand with maturational concerns.
Indeed, these goals are consistent with the PPE and certainly prove the value of the process. Finally, many of the concerns regarding the PPE are generally brought up by specialists who may not be involved in primary care.5 Since the PPE is a primary care event, perhaps the exam should be performed by the primary care provider (PCP). This may decrease the ability of the PPE to determine conditions that may predispose the athlete to sudden death.5 However, the holistic approach of the PCP may be exactly what is needed in this instance. If this approach is not used, then many of McKeag’s goals may not be addressed.
Medical and Legal Issues Related to the PPE
Obviously, protecting the athlete’s physical well-being should be the physician’s primary concern regardless of other possible issues related to the PPE. However, the athlete usually has a strong desire to play and this, along with the desires of other constituencies such as school and parents, may pressure the physician to make a decision that he or she may regret in the future.8 Clearly, this is a primary legal concern. If the physician does not succumb to pressure to "clear" an athlete who may not be ready to play (e.g., due to injury), then he or she has fulfilled a major "duty" of the PPE.
Other duties exist with regard to the PPE. Perhaps a better way to evaluate duty is to begin by a discussion of negligence. In this instance, negligence is defined as conduct of a person that falls below a hypothetical standard of care established by law. The first element of negligence is the duty to conform to this standard of care. Obviously, the first decision that must be made is to determine what that standard of care is. For example, the standard of care of a general practitioner functioning as a sports medicine specialist, is that of a sports medicine specialist. In other words, a PCP may be legally held to a standard of care of someone with specialist training. It is suffice to say that it is critical that the PCP have continuing education in sports medicine and be able to demonstrate evidence of proficiency with this population. The second major concern is with regard to the standard of care. Specifically not all agree on just what that standard is. This is where different "experts" may, in fact, give differing opinions.9
Obviously, duty is inherent in the physician-patient relationship. The question becomes, "How much patient contact is necessary to establish this relationship?" While the "preparticipation physicial examination may not by itself constitute the establishment of a physician-patient relationship," this does not mean that potential physician liability is definitely not involved. Just what constitutes a physician-patient relationship is different, depending on the case law used. In addition, performing the PPE on a volunteer basis does not preclude liability. In other words, just because the physician is not compensated for the PPE does not mean that there is diminished liability. Liability also is not diminished if the sports medicine professional acts as an independent contractor. In fact, acting as an independent contractor may diminish the institution’s liability thereby increasing the physician’s.9
Some believe that the sports medicine professional should consider securing an agreement with the institution in order "to ensure that any claims made against the physican while acting at the institution on behalf of the institution, would be ensured by the institution."9 In this way, the school can be held liable perhaps before the physician. In addition, some institutions have indemnification policies that protect employees.10
It is suffice to say the physician does assume risk when performing the PPE. For this reason and others, it is preferable for the physician to engage in a relationship better defined as the "team physician."11 In this way, the physician can have control over variables for which he or she may be held responsible. This also is a way for the physician to diminish assumption of risk. It is interesting to note that in recent court cases, including Klein Knecht v Gettysburg College, 989 F2d 1360, 3d (Cir. 1993), the primary issue seemed to be the readiness of the school to handle the emergent situation as opposed to whether the condition should have previously been "caught" by a physician.10 The team physician should have an up-to-date knowledge of the following: musculoskeletal system, growth and development, cardiorespiratory function, gynecology, dermatology, neurology, pharmacology, and exercise science.11 As mentioned previously, the PCP who proceeds to become a team physician should make sure that for both legal and ethical reasons, he or she is up to date in a variety of areas. It is also important that he or she has some specific sports medicine continuing education in order to perform these services.
PPE Contents
There are essentially three types of preparticipation examinations described in the literature. The first type of PPE is the office based examination.11 This is an examination generally performed by an individual’s PCP during his/her office hours as another patient appointment. The second type of PPE is the assembly line or locker room system.1,11,12 This is a system in which multiple athletes stand in one line, and the physician goes down the line and performs each individual physical examination technique. For example, the physician may perform a respiratory exam on all athletes and then perform the genitalia exam on all athletes, etc. This type of physical examination is highly risky, and it is generally performed only when there is a significant limitation in time and resources. This environment lends itself to less specificity and greater error and is not advisable. If a community asks a physician to put him or herself into this situation, the physician should decline. The third kind of PPE is commonly called the station format. It is generally done during off hours or on weekends and, therefore, it requires the physician to volunteer his or her time as opposed to being paid for a patient visit to perform the physical as in the office format.12 It is, however, advisable that this be performed in the physician’s office if space permits. In this way, the initial contact with the athlete may turn into a consistent physician-patient relationship. It is also important to note that some authors have concluded that the station system is the best system to determine possible preclusions to athletic participation. Perhaps this is due to multiple individuals interacting with the athlete. Indeed, the athlete may be asked the same question more than once, each time verbalized in a different way. In essence, this system is almost a system of checks and balances, ensuring that the athlete has multiple interactions with health care professionals.4,12-15 Because of the prevelance of the station system in the literature and the author’s own experience with the station system, this system will be addressed in depth. However, before describing the station system, the required features of any preparticipation physical examination, whether it is done in office or the station format, should be addressed ( see Table 1 ).15 In particular, the medical screen should include blood pressure, general appearance, vision, auscultation as part of a cardiovascular exam, respiratory examination, abdominal examination, genitourinary examination, musculoskeletal examination, and integumentary examination. These general areas should be addressed in any history and physical performed in the PPE.
The Station System
Almost every author uses a different number of stations.1,11-13,15,16 The number of stations range from five to 14. Systems that use a smaller number of stations such as the PPE monograph and the Smith system are perhaps the most feasible. In this way, one PCP can perform the medical screen and other highly trained ancillary personnel can perform evaluations at the other stations.12 It is also important to note that space constraints may be a consideration. Sanders has identified two conceptual frameworks based on possible traffic patterns when setting up the station: available space method vs. straight-line method (see Figure 1 ).16 The straight-line method could be used if the examination is performed in a large space such as the locker room with partitions separating the stations. However, as mentioned previously, it is preferable for the exam to be performed in the physician’s office. The available space method would be perhaps the most desirable. In this way, the office could be used efficiently and effectively.
With regard to "who does what," again there is quite a bit of variation in the literature ( see Table 2 ).7 However, all are consistent in two areas. First, the physician performs the medical portion of the exam, and second, and perhaps not as obvious, there should be a physician or other highly trained individual at the check-out station.11-13,16 It is up to this individual to thoroughly review the findings of the exam, to ask pertinent questions one last time, and to ultimately "clear" the athlete for participation.12 For this reason, some have suggested that the physician be the last of the required stations and all other stations after the physician be optional.7 Others have a second physician or other highly trained personnel at the final check-out station to ensure a thorough review of the findings before the athlete is allowed to leave.12 Regardless of how it is done, the final check-out station is of critical importance, even if the physician "cleared" the athlete to compete several stations before. Evaluation at other stations could be performed by physical therapists, athletic trainers, and/or nurses.
Sign-in, height and weight, vital signs, and vision. As stated previously, this first station can certainly be further subdivided and should be performed by ancillary personnel. (In the opinion of the author,) these stations should be performed by health care workers. Specifically someone with a nursing, athletic training, or physical therapy background should attend these stations. Some specific considerations at each station are listed under comments in Table 1.15
Regarding vital signs, obviously, specific attention should be paid to blood pressure. Again, considerations are summarized in Table 1.15 At this station, a review of both personal and family history of hypertension should be the first consideration. While specific quartiles are listed in Table 1, in general, a blood pressure should be based on age-dependent categories and a blood pressure of 135/85 should prompt further evaluation.12,15
As with all stations, this consideration is not just a formality. It is not uncommon to be the first to detect a visual deficit at the PPE. This evaluation can be performed with a standard Snellen eye chart. First, however, personal history of vision should be reviewed. For example, the athlete should be asked if he or she has trouble seeing the chalkboard at school. In general, greater than 20/40 corrected or uncorrected should be further evaluated. Correction to greater than 20/50 should be required for participation in contact sports.12
History review, physical examination, and clearance. As with the first station, some further subdivide this station, depending on personnel. Specifically, many PPEs have someone other than the physician review history with the athlete. If time permits, the physician should by all means perform the history review. This is true particularly if one of the stated goals is to develop a physician-patient relationship. It is also important to note that some suggest that a long form be completed and signed by both the athlete and the parent or guardian before the PPE is initiated.4,12 This is seen as a specific way to increase parent/athlete/physician interaction. It also is possibly more effective than other forms.4,12,17 These forms are long and may include a medical history, review of symptoms, and the physical examination form itself.12
A typical PPE history form that includes specific questions is presented in Figure 2a .11 The majority of both musculoskeletal and medical problems are identified in the history review.17 Obviously, questions that are critical to include are those related to cardiac symptoms in an attempt to identify risk factors for sudden death (see Figure 2a). Again, a few specific concerns are referenced in Table 1 under comments.’11
The physical examination should include at a minimum, a cardio/respiratory examinatioin and a genitourinary examination. (See Figure 2b for example of physical form).7 Again, some specific considerations are listed under "comments" in Table 1 , and Table 3 includes a list of common and uncommon causes of sudden death in athletes. In addition, a musculoskeletal/myotome screen of some type should be done.1,11,12 In this way, both the muscoloskeletal system and specific nerve roots can be checked at the same time. This should include a quick check of posture for significant assymetry, and with the patient in sitting, the following: cervical range of motion, including lateral flexion to both sides, flexion and extension, resisted shoulder shrug (C4 nerve root); resisted shoulder abduction (C5); shoulder internal and external rotation, active and resisted elbow flexion and extension (C6 &C7); forearm pronation, and active and resisted wrist flexion (C8); and extension (T1). The lower myotomes may also be checked with finger abduction and grip strength. The same quick check can be done with the patient in sitting for the lower extremities: active and resisted hip flexion (L2); active knee extension and flexion and resisted knee extension (L3); ankle dorsiflexion and plantarflexion and resisted dorsiflexion (L4); resisted great toe extension (L5); resisted great toe flexion (S1); and resisted knee flexion (S2).18 It is important to note that since the majority of lumbar spine dysfunction such as lumbar disk disease and congenital anomalies such as spondylolisthesis occur at L4, L5, and S1, even in an athletic population, these myotomes should be checked.19
Optional stations. A specific orthopedic examination can be performed if findings indicate a need. Even if findings do not indicate, someone skilled in tests of ligament integrity could be used here to determine the relative health of several major ligaments. This is commonly done in college and professional athletic environments. The test and the ligament that it stresses are as follows: 1) at the ankle: valgus to stress the deltoid ligament, anterior drawer to stress the anterior talofibular ligament, and varus stress to stress the calcaneofibular ligament; 2) at the knee: Lachman or anterior drawer to stress the anterior cruciate ligament, valgus stress to stress the medial collateral ligament, varus stress to stress the lateral collateral ligament, and posterior drawer to evaluate the posterior cruciate ligament; 3) at the shoulder: apprehension test to determine presence of possible anterior subluxation or dislocation secondary to capsular instability and impingement tests to determine the possible presence of subacromial or bicipital impingement; and 4) elbow: valgus to test the integrity of the medial collateral ligament and varus stress to determine the integrity of the lateral collateral ligament.20
Flexibility station. The flexibility station generally involves active range of motion and overpressure at the end range of all of the major joints.16 This includes shoulder flexion extension and abduction, elbow flexion and extension, forearm pronation and supination, hip and knee flexion and extension, and ankle dorsiflexion and plantarflexion. In addition, several special tests can be performed, such as the straight leg raise.
It should be noted that while hypermobility and decreased flexibility have been cited continually as possible predispositions to injury, this has not been proven. In fact, much of the study has not been performed on an athletic population.21,22
Body composition. This station should not be part of the PPE unless the person performing the examination has a great deal of experience performing body composition tests. This person should be highly reliable in performing the test. Body composition is, particularly in the female athlete, one of the most highly charged issues today. Many coaches who use to emphasize decreasing body weight are now emphasizing decreasing body composition. This is not preferable and should not be emphasized due to the significant variability of body composition from measurement to measurement.23 It can be done in a variety of ways, from the pinch method using skin fold calipers, to underwater weighing.
Physical testing. The last two optional stations include several measures of fitness. These are: strength, speed, agility, power, balance, and endurance. These are performed in a variety of ways. For example, strength may be measured by the number of repetitions that the athlete can benchpress a certain weight (commonly done in professional athletics) or by hand grip strength using a hand grip dynamometer. Speed is typically a timed event such as the 40-yard dash, while endurance is typically measured in a mile run or a timed 12-minute run (how many laps the athlete can run in 12 minutes). Several circuit-type obstacle courses test power, agility, and balance. Another common power test is the vertical jump. While these physical performance tests are important, they are generally not used in ruling an athlete out of participation. Instead, these performance measures may be used to determine sports specific profiles.16 For example, Sanders describes a sports specific profile developed by Kibbler, Kibbler & Chandler. This profile identified five basic parameters involved in all sports activity: flexibility, strength, power, anaerobic endurance, and aerobic endurance. A battery of tests have been developed for each of these parameters. The specific test used depends on the specific sport. When the PPE is performed at least six weeks prior to the season beginning, these performance measures can be used to enhance preparation for the upcoming season.
Clearance
As stated previously, identifying potential risks during athletic participation is only one of 11 suggested goals. However, the ultimate decision of whether the athlete should participate in sports should rest with the physician. When a preclusion to participation is found in the PPE, this is likely to be a highly emotional situation with the athlete. The ultimate decision has historically been based on several factors. First, the physician should be aware of the specific classification of sports in which the athlete is to participate. Sports are classified by the American Academy of Family Physicians, the American Academy of Pediatrics (AAP), and the American Medical Society for Sports Medicine. Sports have been classified into two broad categories: contact and noncontact. A list of these classifications appear in Table 4 .1 Soccer, while not on the list, should be considered a contact sport. The athlete should be guided to the appropriate sport possibly based on such factors as findings from Tanner staging.
Obviously, in addition to the classification of sports, the specific medical condition and its relationship to sports participation should be considered (see Table 5 on pages 198-200).11 It should be noted that historically the presence of only one major organ (e.g., eyes, kidneys, or testicles) precluded someone from participation in contact sports. These conditions are a "qualified yes."7 In fact, most chronic illnesses, if properly managed, such as diabetes and convulsive disorders, do not preclude participation.
Specific Considerations for Pre-Adolescence
While the vast majority of this article has been devoted to the adolescent population, our society has continued to focus on organized athletic participation at progressively earlier ages.24 Some specific considerations for this population include the following recommendations: 1) do not specialize too early;24,25 2) group by size and skill, not age;26 3) weight training should not be performed until the athlete reaches Tanner stage 5 or, in general, age 15-18;27 4) a preparticipation physical should be performed every two years on a preadolescent population;26 and 5) in very young children, motor development is best suited in an unstructured environment (nly 20% of 4 year olds are proficient at throwing and only 30% at catching—AAP). When the pre-adolescent does participate in organized sports, the best structure is: 15-20 minutes of structured activity followed by 30 minutes of free play.28 The PCP should be aware of the structured sports environment in which the pre-adolescent athlete is participating. The physician should also be prepared to be an advocate for the pre-adolescent with regard to limited participation in structured sports as advised by the AAP.
Current Controversies
ECG a part of the PPE. While the American Heart Association does not recommend routine use of electrocardiography for screening of high school and college athletes, there are some that suggest this be done routinely, possibly for every athlete.15,29,30 Standard of care at this point is to not use the ECG despite possible advantages, unless indicated from other findings.15
Lateral C-Spine series as part of the PPE. There is current controversy surrounding the width of the spinal canal relative to the vertebral body’s width (torg ratio) and possible predisposition to quadriplegia. Some believe that lateral c-spine x-rays should be performed routinely in the PPE. However, current standard of care is to not do this because the predictive value is still considered controversial. Most believe that spinal stenosis of the cervical spine does predispose to quadriparesis, but not necessarily quadriplegia.
Summary
The preparticipation examination is a critical preventive measure when dealing with the athletic population. Medical legal concerns and logistics are considerations. The station method is an appropriate method and could be used to maximize physician contact with the athlete and hopefully establish a long-term relationship with the athlete.
References
1. Bratton RL. Preparticipation screening of children for sports. Sports Med 1997;24:300-307.
2. Nelson. Organized athletics for preadolescent children. Pediatrics 1989;84(3).
3. Powell JW, Barber-Foss KD. Injury patterns in selected high school sports: A review of the 1995-1997 seasons. Journal of Athletic Training 1999;34(3):277-284.
4. McKeag DB, Sallis RE. Factors at play in the athletic preparticipation examination. Am Fam Physician 2000;61(9):2617-2618.
5. Reich JD. It won’t be me next time: An opinion on preparticipation sports physicals. Am Fam Physician 2000;61(9):2618-2629.
6. McKeag DB. Preparticipation screening of the potential athlete. Clin Sports Med 1989;8:373-397.
7. American Academy of Family Physicians, AAOP, American Medical Society for Sports Medicine, American Orthopedic
Society for Sports Medicine, American Osteopathic Academy of Sports. Preparticipation Physical Examination. 1998. Kansas City, Mo.
8. Mitten MJ, Maron BJ. Legal considerations that affect medical eligibility for competitive athletes with cardiovascular abnormalities and acceptance of Bethesda Conference Recommendations. Med Sci Sports Exerc 1994;26:S238-241.
9. Legal issues in sports medicine. In: Schenck RC, Jr., ed. Athletic Training and Sports Medicine. Chicago, Ill: American Academy of Orthopedic Surgeons; 1999:17-35.
10. Kaplin WA, et al. The Law of Higher Education. San Francisco, Calif: Jossey-Bass Publishers; 1995.
11. Smith D. The preparticipation physical evaluation. In: Mellion MB, et al, eds. The Team Physician’s Handbook. 2nd ed. Philadelphia, Pa: Hanley & Belfus; 1997:24-35.
12. Smith J, Laskowski ER. The preparticipation physical examination: Mayo Clinic experience wtih 2,739 examinations. Mayo Clin Proc 1998;73:419-429.
13. Myers A, Sickles T. Preparticipation sports examination. Prim Care 1998;25(1):225-236.
14. Donahue P. Preparticipation exams: How to detect teenage crisis. The Physician and Sportsmedicine 1990;18(9):53-60.
15. Kurowski K, Chandran S. The Preparticipation athletic evaluation Am Fam Physician 2000;61(9):2683-2690.
16. Sanders B, Nemeth WC. Preparticipation physical examinations. J Orthop Sports Phys Ther 1996;23(2):149-163.
17. Matheson G. Preparticipation screening of athletes. JAMA 1998;279(22):1829-1830.
18. Reese N. Muscle and Sensory Testing. 1st ed. Philadelphia, Pa: WB Saunders Company; 1999.
19. Magee DJ, et al. Shoulder injuries. In: Athletic Injuries and Rehabiliation. Zachazewski JE, Magee DJ, Quillen WS, eds. Philadelphia, Pa: WB Saunders; 1996.
20. Hoppenfeld S. Physical Examination of the Spine and the Extremities. New York, NY: Appleton-Century-Crofts; 1976,
21. Decoster LC, et al. Prevalence and features of joint hypermobility among adolescent athletes. Arch Pediatr Adolesc Med 1997;151:989-992.
22. Gleim GW, McHugh MP. Flexibility and its effects on sports injury and performance. Sports Med 1997;24(5):289-299.
23. McArdle WD, Katch FI, Katch VL. Exercise Physiology: Energy, Nutrition, and Human Performance. 2nd ed. Philadelphia, Pa: Lea & Febiger; 1986:665.
24. Wierrsma L. Risks and benefits of youth sport specialization:
Perspectives and recommendations. Pediatric Exercise Science 2000;12(1).
25. Better Health and Fitness Through Physical Activity. American Academy of Pediatrics; 2000.
26. Committee on Sports Medicine and Committee on School Health. Organized Athletics for Preadolescent Children. American Academy of Pediatrics; 1989.
27. Committee on Sports Medicine. Strength Training, Weight and Power Lifting, and Body Building by Children and Adolescents. American Academy of Pediatrics; 1990.
28. Committee on Sports Medicine and Fitness. Fitness, Activity, and Sports Participation in the Preschool Child. American Academy of Pediatrics; 1992.
29. Fuller CM, et al. Prospective screening of 5,615 high school athletes for risk of sudden cardiac death. Med Sci Sports Exerc 1997;29(9):1131-1138.
30. Fuller CM. Cost effectiveness of analysis of screening of high school athletes for risk of sudden cardiac death. Med Sci Sports Exerc 2000;32(5):887-890.
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