Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018

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On Sep 2018

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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

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Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Case report
Year : 2022 | Month : May | Volume : 16 | Issue : 5 | Page : OD01 - OD04 Full Version

Diffuse Large B-cell Lymphoma-Treatment Failure, Recovery and COVID-19: A Case Report

Published: May 1, 2022 | DOI:
Ponvijaya M Yadav, Rupesh S Parati, Vijayshree S Gokhale, Dhiral R Mahajan, Atiullah Imran Malik

1. Resident, Department of General Medicine, Dr. D.Y. Patil Medical College, Pimpri, Pune, Maharashtra, India. 2. Resident, Department of General Medicine, Dr. D.Y. Patil Medical College, Pimpri, Pune, Maharashtra, India. 3. Professor, Department of General Medicine, Dr. D.Y. Patil Medical College, Pimpri, Pune, Maharashtra, India. 4. Resident, Department of General Medicine, Dr. D.Y. Patil Medical College, Pimpri, Pune, Maharashtra, India. 5. Senior Resident, Department of General Medicine, Dr. D.Y. Patil Medical College, Pimpri, Pune, Maharashtra, India.

Correspondence Address :
Dr. Rupesh S Parati,
Resident, Department of General Medicine, Dr. D.Y. Patil Medical College, Pimpri, Pune-411018, Maharashtra, India.


Diffuse Large B-cell Lymphoma (DLBCL) is the most common form of non-hodgkin lymphoma, involving multiple organ system including lymph node, bone marrow, spleen etc. Among overall cases of DLBCL, 40% are extranodal in origin and stomach being the most common site. While most of the (60%) are not diagnosed until the disease reach stage 3 or 4. While in the present case of a 65-year-old female, patient had predominant involvement of neck lymph nodes. Following the final diagnosis, patient was given first line treatment in the form of Rituximab, Cyclophosphamide, Hydroxydaunorubicin hydrochloride (doxorubicin hydrochloride), vincristine (Oncovin) and Prednisone (R-CHOP) regimen, to which patient didn’t respond and further the patient was given Rituximab, Ifosfamide, Carboplatin, and Etoposide (R-ICE) regimen, to which patient responded quickly. With Coronavirus Disease 2019 (COVID-19) pandemic, the patient encountered infection with its associated complication. The following case report is all about the timely management of DLBCL and patient’s survival with COVID-19 and its related complication. Haematological malignancy such as lymphomas, leukaemias, myelomas cause severe myelosuppression and lymphodepletion increasing the risk for development of COVID-19. Studies have shown that patients with malignancy had an estimated two-fold increased risk of contracting Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2) than the general population. The survival rates strongly depend on COVID-19 stage and other factors such as immune (neutropenia) status and systemic inflammation.


Chemotherapy, Haematological malignancy, Lymphoma, Non hodgkin lymphoma

Case Report

A 65-year-old female was brought to the Emergency Department with a complaint of right side neck swelling for three months and constitutional symptoms like a low-grade fever, decreased appetite, weight loss around 8-10 kg in last six months. The subject had no other underlying co-morbidity including diabetes and hypertension. While on a detailed history, she didn’t have a previous history of viral infection, drug allergies, drug intake or addictions.

On examination, there were multiple discrete swellings noted largest measuring approximately 2×2 cm with ulcerations and serous discharge, while no other lymph nodes palpable clinically. Patient was later subjected to laboratory investigations as shown in (Table/Fig 1) and ultrasound of neck which showed multiple hypoechoic lymph nodes of size 1-2 cm at level II-IV and submandibular region suggestive of neoplastic aetiology. Considering the fact as revealed in ultrasound that patient was suffering from underlying malignancy, she was referred to onco-physician and was advised Fine Needle Aspiration Cytology (FNAC) and excisional biopsy and immunohistochemistry. The FNAC of right cervical lymph node (1st initial biopsy) showed Non-hodgkin’s lymphoma, excisional biopsy of right cervical lymph node showed proliferation of large lymphoid cells, with elongated, pleomorphic, and prominent nucleoli along with few scattered small lymphocytes (Table/Fig 2). Immunohistochemistry showed neoplastic lymphoid cells which were strongly positive for CD45, CD20, CD10, Bcl2 and Bcl6 and negative for Pan CK, HMB 45 and C3. Ki-67 index was 65 percent. The findings were consistent with primary cutaneous DLBCL.

Along with the available investigation, patient was referred to oncologist and the working diagnosis of primary cutaneous DLBCL was made and the patient was advised chemotherapy. Prior to the investigations all laboratory investigations were repeated which were consistent with previous ones.

The echocardiography and electrocardiogram study was within normal limits prior to the initiation of chemotherapy.

Four cycles of chemotherapy regimen (R-CHOP regimen) were administered uneventfully, but no significant improvement was noted suggesting the treatment failure. An expert opinion of oncologist was sought, who opined that patient must undergo PET scan study (Table/Fig 3) which showed hypermetabolic bulky right neck nodal mass. Hypermetabolic bilateral cervical nodes. Low grade metabolic activity seen in bilateral axillary, internal mammary and left abdominopelvic nodes. The above scan was performed after the fourth chemo, suggesting the treatment failure.

Repeat biopsy showed neoplastic lymphoid cells showing strong diffuse positivity for CD20, CD10, Bcl-2 and Bcl-6 while they were negative for MUM-1 and C-MYC (20%). MiB-1 labelling index is high (70%). Diffuse large B cell Lymphoma involving skin-germinal center B-cell (GCB type: Hans Algorithm) was observed.

The Oncologist, considering the treatment failure, decided to modify the further cycles of chemotherapy as:

Cycle 5: R-ICE regime-Rituximab (500 mg)+ICE regime given to which patient responded, the swelling size was on the decreasing trend.

Cycle 6: R-ICE regime-Rituximab (500 mg)+ICE regime given to which patient responded and substantial decrease in the size was noted in next few weeks.

Following the sixth cycle completion patient started responding clinically and was discharged with the nursing care and was asked to follow-up for seventh cycle of chemotherapy. Eighteenth day following the seventh cycle of chemotherapy, patient developed fever with chills along with the dry cough. Considering the possibility of COVID-19, the swab was sent for Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) which turned out to be positive and she was started on the following treatment and further cycles of chemo was deferred as advised by oncologist. (Table/Fig 4) shows the levels of inflammatory markers on third and 21st day of COVID-19. The treatment advice for COVID-19 is outlined in (Table/Fig 5).

On third day of COVID-19 illness, the subject developed sudden onset of breathlessness and unexplained tachycardia, while ECG was substantiating only sinus tachycardia. While taking into account the malignancy induced hypercoagulable state and prothrombotic nature of COVID-19 illness and considering the possibility of pulmonary embolism, patient underwent various investigations including inflammatory markers as depicted in (Table/Fig 4) and CT Pulmonary-Angio (Table/Fig 6), which revealed partial filling defect in bilateral posterior basal and right side lateral basal arteries and distal branches suggesting thrombosis and Computed Tomography (CT) severity index was 24/25. Other radiographic and clinical pictures are provided in the (Table/Fig 7), (Table/Fig 8).

On day 8 of illness, patient was weaned off from oxygen support and was shifted to normal ward. As the patient was immunocompromised due to pre-existing DLBCL and underlying COVID-19, the eighth cycle of chemotheraphy was deferred for next three months and the decision was completely subjective, and was taken by the panel of oncologist considering the risk of chemotherapy induced complication versus its benefit in the current situation. Further she was discharged on Pirfenidone and Rivaroxaban. Currently the patient is under follow-up and next four cycles of chemotherapy has been administered successfully.


Herein reporting a case of Diffuse Large B-cell lymphoma (DLBCL) which is the most common histologic subtype of NHL complicated with COVID-19 pneumonitis and Acute Pulmonary Thromboembolism. Median age at diagnosis is 70 years (1),(2). While patients like this who presents as a cervical lymph node enlargement in developing country like India, the first differential diagnosis would be tubercular lymphadenitis/cold abscess while in western countries it will mostly be lymphoma. However, other differential diagnoses comprise of infectious mononucleosis, Hodgkin, T-cell mediated lymphomas. Similarly, other malignancies such as carcinomas, melanoma, and Kikuchi disease can also be considered. When melanomas are considered as differential, it can be differentiated from DLBCL by (+) S100, HMB-45 and Melan A Staining. Therefore, urgent investigation and biopsy is indicated to confirm the final diagnosis. (3),(4),(5)

While in current scenario DLBCL was established as final diagnosis on HPE. The DLBCL peculiarly appraise diffuse proliferation of large, atypical lymphocytes with high proliferative index and typically express the B-cell antigens CD19, CD20, and CD79a. The BCL-2 is overexpressed, whereas BCL6 is positive in more than two-thirds of cases. While in this case, proliferation of large lymphoid cells, with elongated, pleomorphic, and prominent nucleoli along with few scattered small lymphocytes were noted. Neoplastic lymphoid cells were strongly positive for CD45, CD20, CD10, BCl2 and BCl6. and negative for Pan CK, HMB 45 and C3. Ki 67 index is 65% (5),(6),(7).

Following the diagnosis of DLBCL, the oncologist advised to initiate the six cycles of R-CHOP Regimen of which four cycles were given uneventfully, but no response was noted; in fact, the size of swelling increased (8),(9). Considering the possibility of treatment failure, patient was advised Positron emission tomography (PET) scan and Repeat Biopsy as mentioned above. After the due consultation with oncologist was done with repeat PET reports and Biopsy and the regimen was modified to R-ICE to which patient responded promptly as mentioned in the case scenario.

With conventional chemotherapy, high rates of treatment failure were regarded and this was taken into the account by Nowakowski GS et al., (10). They concluded that, there are lots of hurdles and challenges that needs to be overcome to accurately identify the molecular subsets and to govern the specific chemotherapeutic modality and targeted therapies. The pivotal strategy should be to maximise cure rates and favourable treatment outcome so as to enhance long-term survival along with curtailing the chances of toxicity. The current and future trails must be intended to improve the overall clinical outcome of patient by using biologically active compound. While additional strategy must be chalked out to address the treatment failure and include the novel and targeted agents.

Kewalramani T et al., concluded in their literature that those patient developed relapse or those had primary refractory (DLBCL) who achieve complete response (CR) prior to the autologous stem cell transplantation (ASCT) usually have better prognostic outcomes when compared to those who accomplished just partial response (PR). The study concluded that adding Rituximab to ICE combination increases the possibilities of complete response in the patients with DLBCL who are under the consideration of autologous stem cell transplant (11). Similarly, in present case, patient was shifted from R-CHOP to R-ICE regimen, and patient achieved complete response.

Unfortunately, the patient was encountered with COVID-19 pneumonitis with acute pulmonary thromembolism and severe Acute Respiratory Distress Syndrome (ARDS) and was on Non Invasive Ventillation (NIV) support. Patient already being an immunocompromised, was more prone to secondary acquired infection and was initiated with the treatment as mentioned in (Table/Fig 5). However, administering Tocilizumab was not considered due to its side-effect profile and its potency to flare the immunocompromise state that itself can precipitate opportunistic bacterial and fungal infection. Despite patient being immunocompromised with evidence of severe neutropenia, responded to the above treatment and was weaned off from NIV and oxygen support in next seven days and was continued with rivaroxaban. Patient was later given remaining cycles of R-ICE regimen successfully. Currently patient had complete remission. DLBCL being most common form of Non-hodgkin lymphoma. The R-CHOP regimen is a standard first line treatment whereas R-ICE is also considered in a patient who had relapse and treatment failure (11),(12). The autologous stem cell transplant is also a promising treatment; more supportive studies are needed in this regards. While target novel drugs can also be used when there is a failure of R-CHOP regimen or R-ICE regimen. It’s the corollary that haematological malignancy such as lymphomas, leukaemias, myelomas cause severe myelosuppression and lymphodepletion increasing the risk for development of various virus infections such as COVID-19. Studies have shown that patients with malignancy had an estimated two-fold increased risk of contracting SARS-CoV-2 than the general population as concluded by Dai M et al., in their multicentric study (13).


The DLBCL being most common form of non hodghkin lymphoma. The R-CHOP regimen is a standard first line treatment whereas R-ICE is also considered in a patient who had relapse and treatment failure. The autologous stem cell transplant is also a promising treatment; although more supportive studies are needed in this regards. While target novel drugs can also be used when there is a failure of R-CHOP regimen or R-ICE regimen. It’s the corollary that haematological malignancy such as lymphomas, leukaemias, myelomas cause severe myelosuppression and lymphodepletion increasing the risk for development of various viral infections such as COVID-19 and during such circumstances, patients must be treated aggressively and with full aseptic precaution in an isolation settings.


Authors acknowledge the Department of Pathology for their support.


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DOI and Others

DOI: 10.7860/JCDR/2022/55715.16309

Date of Submission: Feb 15, 2022
Date of Peer Review: Mar 10, 2022
Date of Acceptance: Apr 01, 2022
Date of Publishing: May 01, 2022

• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

• Plagiarism X-checker: Feb 17, 2022
• Manual Googling: Feb 23, 2022
• iThenticate Software: Mar 25, 2022 (8%)

ETYMOLOGY: Author Origin

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