In this episode of the Sarasota Neurology Podcast, Dr. Kassicieh, a recognized Parkinson’s disease expert, provides an overview of the disease and current techniques for managing it.

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Parkinson’s disease is the second most common neurodegenerative disease seen in the United States. Only Alzheimer’s disease is more common. They both share the common fact that they are progressive neurological diseases that result in patients losing functional ability. Alzheimer’s disease affects memory, the ability to remember how to do things and general loss of mental function. Alzheimer’s patients are mostly not aware of the fact that they are neurologically deteriorating. They will make excuses for their memory short comings. Like Parkinson’s disease it is important to recognize Alzheimer’s early so that treatment can be started and outcomes will be improved.

Parkinson’s disease is primarily a progressive loss of the ability to move normally. There is a gradual slowing of movements as well as doing routine tasks such as shaving, dressing and getting ready to go out. Walking is affected and patients tend to shuffle with a forward stoop. Although tremor is common in Parkinson’s patients, not all have this. The converse is true: not everyone with tremor has Parkinson’s disease. There are many treatment available for Parkinson patients to improve their quality of life.

Not everything that shakes is Parkinson’s. If you are concerned that you or someone you love may be suffering from this or another movement disorder, please call (941) 955-5858 or click here to schedule your appointment today. If you’re outside the Sarasota area and unable to travel here, please locate a movement disorder specialist in your area.


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How I Avoided Knee Surgery

Parkinson disease was first described by James Parkinson in 1817 Over the years, various medication therapies have been FDA approved for Parkinson disease. In the 1960s, Sinemet (carbidooa-levodopa) was approved. Sinemet was and still is the gold standard therapy for Parkinson disease. While it is the gold standard, it should not be the first drug used to treat Parkinson disease. It should be the third or fourth drug used. Early use of Sinemet can result in unwanted, irreversible side effects.

Dopamine agonist were FDA approved in the 1990s for first line Parkinson disease therapy. These medications mimic the effect of dopamine in the brain of Parkinson disease patients. Dopamine is the brain chemical that is deficient in these patients. Mirapex (pramipexole) and Requip (ropinirole) are two commonly used dopamine agonists in the treatment of Parkinson patients.

The newest dopamine agonist which was FDA approved for Parkinson treatment is Neupro. Neupro is unique in that it is a dopamine agonist patch medication. This transdermal patch system is applied once daily to clean, dry skin. The benefit is that Parkinson patients get a 24 hour continuous medication dosing. Patch application sites need to be rotated daily, to prevent skin irritation. Neupro comes in several dosage strengths. Like other Parkinson medications, the dose needs to be adjusted for ideal patient functioning, with minimal side effects.

Dopamine agonists can have potential side effects. This class of medication can cause symptoms of hallucinations, confusion, lowered blood pressure, drowsiness, sudden sleep attacks – particularly while driving. Other side effects include stomach upset, nausea and compulsive behaviors – including gambling, eating and hypersexuality.

Parkinson disease does not need to be a disabling condition. With careful neurological management and detail to your specific needs, a Parkinson patient can have an excellent, functional quality of life for many years.


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Parkinson’s disease is a complex constellation of symptoms. As reported in the August 30, 2011 issue of Neurology, neurologist care of Parkinson patients greatly improves their quality of life and long term clinical outcome. Parkinson disease affects approximately 1 million Americans. It is only second to Alzheimer’s disease as a common neurodegenerative illness. Early diagnosis, recognition of associated symptoms and comorbidities as well as comprehensive care are necessary if a Parkinson patient’s long term clinical outcomes and quality of life are to be maintained.

Neurology has commonly not been taught in the detail that is necessary in most medical schools. Medical students graduate, generally with a limited understanding of neurological diseases and the treatment required for each. Neurology has a vast scope of illnesses, each requiring intimate knowledge and understanding of the disease process as well as the treatment required to optimize patient well being and life quality. It is beyond the scope of medical school, internship and even family medicine or internal medicine residencies to train the young physician sufficiently in the details of neurological disease.

Across the United States, 15-20% of all visits to a primary care doctor’s office (family physician or internal medicine) involve a neurological complaint. While simple problems such as back or neck pain can easily be treated, more complicated illnesses such as Parkinson’s disease, migraine headaches, seizures and multiple sclerosis should be managed by a neurologist – particularly a sub-specialist neurologist in the disease process needing treatment. Surveys in the United States, Europe and Asia show that both medical students and general physicians do not feel as comfortable in managing neurological problems as they do other common medical problems.  The article in Neurology clearly shows that Parkinson patients, managed by a neurologist, have overall better outcomes than those managed by family physicians.

Parkinson patients managed by  a neurologist have  an earlier diagnosis. This leads to starting treatment earlier. With early intervention, patient functioning can be maintained and optimized. This allows for the patient and their families to enjoy more quality time together with an increased ability to engage in social activities and travel. The study reported in Neurology, looked at over 138,000 Parkinson patents. The finding of this study showed that about 20% of patents with Parkinson’s disease never see a neurologist. These patients had a higher rate of falling, hip fractures, nursing home admission and death at an earlier age.

Parkinson patents cared for by a neurologist, by contrast, significantly had fewer hip fractures. Hip fractures are a major cause of disability and death in the elderly. Inherent to Parkinson patients is gait instability and a tendency for stumbles and falls. Falling prevention is a main goal in all elderly patients, but particularly those with Parkinson’s disease. Unfortunately, many who suffer a hip fracture may become wheelchair confined, even with successful hip fracture repair.  One third of all patients who suffer a hip fracture will die within a year of their fracture! The annual cost of managing a patient with a hip fracture is $20,000 per person – not including medical costs. With detailed care of all of a Parkinson patients symptoms, a neurologist can better prevent these patients from falling and suffering fractures.

The second finding of this study was that Parkinson patients getting state-of-the-art care by a neurologist had a lower probability of being admitted to a nursing home. While most Parkinson patients do not need nursing home care, those with more advanced disease, Parkinson related dementia or complications such as hip fractures frequently need skilled nursing facility placement. Parkinson’s disease is complex condition. Not only are the motor symptoms a major problem, but so are the cognitive and psychological problems that go along with this disease. Depression and anxiety occur in over fifty percent of Parkinson patients. Early recognition and treatment  is critical for improved patent and caregiver quality of life. Dementia is also a common problem. It can start as mild memory loss but will progress. Neurologists are sensitive to these problems and there are medications as well as dietary supplements that help to improve these problems.

The final finding of the Neurology study was that there was a statistically significant increase in the six year survival of patients with Parkinson’s disease managed by a neurologist. There are multiple reasons why this may be the case, including earlier use of the many types of medications used in Parkinson management, treatment of coexisting psychiatric problems and addressing the multitude of other medical problems that are frequently associated with Parkinson’s disease.

The conclusion for Parkinson patients and their family or caregivers is to get that patient into see a neurologist, particularly a neurologist who specializes in movement disorders. Patients want more control over their life, improved quality of life and the ability to remain functional as long as possible. This is true for the Parkinson patient as well. Take control of your life, contact Sarasota Neurology for consultation and management of your Parkinson’s disease. It will most likely be the best thing you could do for yourself – for the rest of your life.


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Parkinson’s disease is the second most common neurodegenerative disorder, just behind Alzheimer’s disease. Parkinson’s disease is characterized by specific clinical symptoms including rigidity (stiffness), slowness of movement, unsteadiness (gait imbalance) and tremor. For the accurate diagnosis of Parkinson’s disease to be made, a patient needs to have 3 of the 4 major symptoms of the disorder. Each patient with Parkinson’s disease is different and may have differing degrees of each component of Parkinsonism. Not all patients with Parkinson’s disease have tremor. Some may have more instability of gait, shuffling or slowness of movement. There are several medications available that neurologists can use to treat Parkinson patients to alleviate their Parkinson symptoms and improve their overall quality of life. Unfortunately, there is a down side to this treatment. Patients who have been on Sinemet for a few years tend to develop motor fluctuations. Motor fluctuations include end-of-dose wearing off, where their functional abilities deteriorate before the next dose of medication is due. Other motor fluctuations include freezing and off time.
Parkinson freezing is simply when a patient becomes “stuck” meaning they cannot move. This occurs more frequently when going through doorways, stepping up onto a curb or stair or when getting up to start walking. Freezing can also occur first thing in the morning, just when getting up out of bed. Freezing episodes can last for a second up to a few minutes. It is the goal of every Parkinson’s disease neurologist to minimize a patient’s amount of freezing, through various medications and dosing schedule changes. Off time can occur in two settings: one is predictable, usually at the end of the dosing interval but the other occurs randomly, without warning. These sudden off time events are more problematic as they tend not to respond as well to medication changes. Off time is troublesome for the patient and caregiver. Affected patients become virtually immobile, essentially frozen in place. There are different degrees of off time, but in all cases, the patient’s mobility and ability to function are severely impaired. Off time may last minutes to hours. For those patients with short duration off time, additional medication or shorter dosing intervals usually will help. Off time may also occur first thing in the morning when waking up. Even if Parkinson patients take their medications, it may be an hour or more before they are functioning normally. For patients with prolonged off times, usually greater than 45 minutes, there is treatment.
Apokyn (apomorphine) is a self administered injectable medication that rapidly relieves off time. Its duration of action is generally less than 2 hours. This is an ideal medication for patients with one or multiple daily freezing episodes. For those affected patients, Apokyn can literally give them their lives back, particularly when more waking hours are spent in the “off time” than in “on time.” For a patient or caregiver to administer Apokyn, some training is required. This is covered by the drug manufacturer and by Medicare. Side effects can include a drop in blood pressure, lightheadedness, nausea or vomiting. When initially starting a patient on Apokyn, medication to prevent nausea is given first. After being on the Apokyn for a few weeks, patients frequently can stop the antinausea medication.
If you are a patient or caregiver and feel that Apokyn may be of benefit, contact your neurologist or Parkinson disease specialist for more information. An excellent information package, with DVD, is available at no cost. The first step is to make the call to improve your quality of life.  For more information, visit the website for Dr. Kassicieh at: www.DrKassicieh.com.


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There are many studies that have shown excellent health benefits from taking omega 3 type fish oil. Omega 3 oils are found in fish oils, flax seed and several vegetable oils including canola, soybean and olive oils. There are different components to these oils that provide health benefits. The DHA and EPA oils in fish oil have been linked to reducing hardening of the arteries and lowering triglycerides. They also have the benefit of lowering blood pressure and heart rate to a mild degree. This all results in an overall reduction in risk for coronary artery disease, heart attack, sudden death, irregular heart beat and stroke. Fish oil can also have a blood thinning effect to reduce abnormal blood clotting, similar to that of aspirin. This latter effect is a two edge sword because too much fish oil can increase the risk for serious bleeding. Generally three grams (3000 mg) daily or less is considered safe. Daily intake of Omega 3 should come from dietary sources with no more than 2000 mg (2 grams) coming from supplements.

Omega-3 is derived from high fat containing fish such as albacore tuna, salmon, flounder, pompano, anchovies, sardines and mackerel. Fish in the equatorial regions around South America have a higher content of Omega 3 than do those caught in the more northern areas around Scandinavia and Iceland. Interestingly flax seed, flax oil and kiwi fruit contain higher amounts of Omega 3 oils than do that of fish. Flax seed can be added to cereal, baked goods or eaten alone. Fish oil capsules are available in 1000 mg and 1200 mg sizes. It is important to not confuse Omega-3 oils with Omega-6 oils. Omega-6 oils do not confer the health benefits that Omega-3 fish oils do. Omega-6 is found in high concentrations in various types of vegetable oils derived from the following: corn, safflower, sesame, soybean, sunflower and walnuts. It is important to reduce the consumption of Omega-6 oils as they compete with Omega-3 oils, thereby decreasing the benefit from Omega-3 fish oils. Eating fish twice a week is the standard recommendation, in addition to taking any supplements.

There have been many studies showing the beneficial effects of Omega-3 oils. The main benefit comes from reduction of hardening of the arteries (atherosclerosis), reduced coronary artery disease, decreased risk of heart attack and potentially fatal heart beat rhythms. Omega-3 oils have also been shown in some studies to have a brain cell protective effect in such conditions as Alzheimer’s and Parkinson’s disease. Fish oils can improve memory to a degree. Several studies have shown that 2000-3000 mg of Omega-3 oil intake daily, has a potent antiinflammatory action as that of high dose ibuprofen. Patients with arthritis or rheumatoid arthritis may benefit from Omega-3, without the risks associated with taking
antiinflammatory drugs for extended periods (such as bleeding stomach ulcers, kidney and liver damage.) It should be noted that the fish oil capsules have a more robust effect for reducing inflammation than that of flax seed oils.

Omega-3 oils can reduce total triglyceride levels and increase “good” cholesterol (HDL) levels. These oils also have an overall beneficial effect on the blood vessels, both in increasing blood flow and improving the health and stability of the vessel walls themselves. This effect is in part responsible for the risk reduction in having a stroke or heart attack as well as patients with problematic varicose veins and leg pains due to peripheral vascular disease. A word of caution: in patients with congestive heart failure, consultation with your cardiologist is first advised. As fish oil has a blood thinning effect, you should check with your doctor if you are taking prescription blood thinners. Additional benefits from Omega-3 fish oils have been shown in improving retinal (visual) function and possibly slowing down macular degeneration. Studies in psychiatric conditions have demonstrated Omega-3 beneficial effects in reducing depression, lessening memory loss and improving memory function.


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Recent studies have suggested that qualifying Parkinson patients benefit from earlier treatment with deep brain stimulation, as reported in Clinical Neurology News. The study indicates that younger Parkinson disease patients are more likely to benefit from early brain stimulator treatment. There is information that may suggest that this therapy may have a protective effect in delaying the progression of Parkinson’s disease. Deep brain stimulation (DBS) was FDA approved in 2002 for treatment of Parkinson’s disease. Symptoms that are best controlled include tremor and dyskinesias although brain stimulation can also help reduce freezing and off time. Younger Parkinson patients develop motor complications such as dyskinesias, off time and freezing much earlier than older patients with Parkinson’s disease. As reported by Dr. David Charles, a Vanderbilt University Medical Center Parkinson neurologist, “No therapy…has bee shown to slow the progression of Parkinson’s.” The previous thinking was to wait until a patient had severe motor complications that could not be controlled with medications prior to considering DBS therapy. The new thinking, and research, is exploring benefits of DBS in earlier stages of Parkinson’s disease. In various reported cases, patients not only benefited from better control of their Parkinson motor symptoms but also had improved quality of life. Added advantages is that Parkinson patients treated earlier with DBS used less medications over an 18 month period, as shown in one small study. There are two studies currently looking at the benefits of early DBS therapy in Parkinson patients: EARLYSTIM is a French study and a smaller study at Vanderbilt University are in progress. It should be noted that Parkinson’s disease is a progressive neurodegenerative disorder. Even patients with DBS therapy do have progression of their symptoms. Memory loss can be a part of the Parkinson syndrome and is not helped by DBS therapy. DBS is not a substitute for optimal neurological and medication management of Parkinson symptoms. Dr. Kassicieh, at Sarasota Neurology, provides medical and neurological management for patients with Parkinson’s disease and brain stimulators. For more information click here.


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Neupro patches were approved by the FDA for Parkinson’s disease treatment in September 2007. They proved to be very effective in the control of Parkinson symptoms, as compared to the effects of other dopamine agonists including Mirapex and Requip. Unfortunately, in March, the FDA recalled Neupro due to problem with the patch delivery of the medications. What they found posed no imminent danger to patients. Rather what was happening was that the active drug, rotigotine, was crystallizing in the patch therefore not delivering the full dosage of medication to the patient. What would happen is that affected patients’ Parkinson symptoms would not be as well controlled. It is not clear if Neupro patches will be brought back to market as reported on Emaxhealth.

Dopamine agonists remain one of the main Parkinson treatment medication groups available to control Parkinson symptoms. These can be used as first line medications for early Parkinson’s disease, showing as good as an effect as Sinemet – the gold standard for treatment of Parkinson’s disease. Many feel that it is beneficial and studies have shown that starting early treatment with dopamine agonists can limit the long term side effects of starting Sinemet early. This is particularly true for delaying development of dyskinesia, which are involuntary movements of arms, legs and head. Dopamine agonists can also help to suppress tremor associated with Parkinson disease.

If you are still using Neupro patches, you should contact your treating neurologist or Parkinson specialist to get the weaning patches and titrate off this drug. Many other excellent treatments for Parkinson’s disease are available. For more information visit: Parkinson Doctor.


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Normal pressure hydrocephalus (NPH) is a rare disorder that is characterized by progressive gait difficulty, urinary incontinence and memory loss. Although the press has covered this topic extensively in both the written and video media, true normal pressure hydrocephalus remains quite uncommon. The underlying problem is actually an excessive build up of spinal fluid in the brain. The areas of the brain that stores this fluid are known as the ventricles. In NPH, the spinal fluid flows out of the brain but, due to reasons that are not entirely clear, there is a build up of excessive fluid in the brain. This results in enlarged ventricles causing a condition called communicating hydrocephalus.

Normal pressure hydrocephalus develops very slowly, over months to years. It is usually seen in individuals over the age of 65. As the ventricles slowly increase in size, affected patients begin to show signs of slowed, wide based, unsteady gait. Urinary incontinence may also develop during this time. Later during the disease process memory loss begins. All of the symptoms are very slowly progressive. Patients can be diagnosed incorrectly with Parkinson’s disease, Alzheimer’s disease, depression or just dementia.

The gait difficulty comes from the fact the the nerve fibers that control walking and balance become stretched as the ventricles enlarge. With this comes progressively worsening gait imbalance and falling. Patients may complain of weakness and fatigue. Patients will actually will tell you that their feet feel stuck to the ground, giving rise to the term magnetic gait. Memory loss seen in normal pressure involves mainly recall and slowness of thinking. Recognition of objects, tasks and individuals is better preserved. Without careful testing however, one can easily make the mistake of making an erroneous diagnosis of Alzheimer’s disease versus normal pressure hydrocephalus associated dementia. Urinary incontinence is a later finding in the disease process. There is an increasing need to urinate more frequently and urgently. If the dementia progresses too far, patients will become indifferent to their incontinence.

Diagnosis is made by obtaining an MRI or CT brain scan. The ventricles appear enlarged in the absence of brain atrophy (shrinkage.) As a normal process of aging, there is a certain amount of atrophy. It other conditions such as Alzheimer’s disease, alcoholism or in patient’s who have received chemotherapy, brain atrophy can be more prominent. The key in diagnosing NPH is that the degree of ventricular enlargement is out of proportion to the expected degree of atrophy. The degree of ventricular enlargement can be measured as a ratio to the degree of atrophy. The second step in diagnosis, after a complete neurological exam, is to do a diagnostic spinal tap (lumbar puncture.) During this procedure, 1-2 ounces of spinal fluid is drained off. The patient is then tested to see if their gait improves.

Treatment for confirmed cases of normal pressure hydrocephalus is a brain surgery procedure know as a ventriculoperitoneal shunt placement. In this procedure, a tube is placed in the ventricles and the other end drains into the abdomen. The tube is run under the skin. Spinal fluid is then absorbed in the abdomen. There is no known effective medical treatment for NPH. Early diagnosis and treatment is important as the gait disorder and urinary symptoms can be alleviated. Once the memory loss has begun, this cannot be reversed.

In order to have the accurate diagnosis of normal pressure hydrocephalus, a patient should be seen by a neurologist or neurosurgeon familiar with the condition. It is not necessarily easily diagnosed, even by experienced physicians. Nonspecific gait disorder is common with advancing age. Dementia is also common, particularly over the age of 70. Stroke, Parkinson’s disease and low thyroid can mimic the symptoms of normal pressure hydrocephalus. The main point is that of all these conditions, true normal pressure hydrocephalus occurs very rarely and is generally considered a diagnosis of exclusion of every other problem plus meet the diagnostic criteria listed above.


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The FDA has recently approved the dementia fighting drug Exelon in a patch form. The new formulation, Transdermal Exelon, offers patients a new and unique way to get medication which can help with improving cognitive function and slow down memory loss in patients suffering from Alzheimer’s disease. The new patch is also FDA approved for patients with Parkinson associated dementia. This is the second patch approved for use in treatment of Parkinson disease. The other is Neupro, a transdermal patch containing the dopamine agonist rotigotine.

Transdermal Exelon joins the group of other medications used to treat Alzheimer’s disease, such as Aricept, Razadyne and Namenda. The patch for of Exelon offers the advantage of not having to take a pill twice daily, continuous medication administration through the skin and less stomach upset. Another advantage is that the patch demonstrated beneficial effects equivalent to the maximum oral dosing of this medication. The problem with the oral medication was intolerance due to nausea and vomiting. While much less, there were some reports of stomach upset with Transdermal Exelon. Another side effect, common to most patch medications, was that of skin irritation. The patch needs to be changed daily and administration sites should be rotated, not using the same site more than once every two weeks. While Exelon, Aricept and Razadyne are in the same chemical family of memory disorder drugs – the acetylcholine esterase inhibitors – Namenda is in a class by itself. For this reason, it can be used in combination with any of the other three. Studies have shown that there is a beneficial effect in improving cognitive function with combining these two different types of medication. Studies are looking into the use of these medications for patients with mild cognitive impairment. These are individuals who have some memory loss but do not fit the criteria to be diagnosed with dementia. Depression, manifesting as dementia, also needs to be excluded.

Alzheimer’s disease is a chronic debilitating illness that slowly robs patients of their memory, cognitive abilities and ability to function independently. They become more and more dependent on others to provide care and transportation for them. Even dressing, eating and bathing become impossible for them to perform without assistance. With the availability of these new memory drugs, the progression of the debilitating symptoms of Alzheimer’s disease and Parkinson disease associated dementia can be slowed down. Some patients actually show functional improvement. Unfortunately, none of these medications halt the progression of the disease. Eventually their quality of life deteriorates and others will need to assist with care giving. The benefit of these medications is that they significantly slow the progression of the disease, possibly keeping loved ones at home, instead of a nursing home, for anywhere from 6-18 months. If you have a loved one with memory loss, early diagnosis and treatment is important. Studies are ongoing to show that with earlier treatment, patients do better over extended periods of time. Bring your family member with memory loss to a neurologist for a complete evaluation.


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The FDA has approved a new medication therapy for the treatment of Parkinson’s disease. The new drug is rotigotine (Neupro), which is in the family of dopamine agonists. Dopamine agonists mimic the effects of levodopa (Sinemet) without having to go through chemical transformation. Other dopamine agonists include Mirapex and Requip. Neupro is different in that it comes in the form of a patch. This has the advantage that the medication is delivered continuously through the skin, while you are wearing the patch. Theoretically, this would provide a more even blood concentration of medication throughout the day. Patients using Neupro should not be taking one of the other dopamine agonists. This patch can be used alone or in combination with other Parkinson medications, to help improve the daily function of patients affected with Parkinson’s disease. Side effects include low blood pressure, foot swelling, hallucinations and stomach upset – just like the other dopamine agonists. Neupro can also cause contact dermatitis (rash) from the patch adhesive. This is similar to what some patients experience with bandages and medical tape. The dopamine agonists help Parkinson patients in many ways including use of less Sinemet and decreasing dykinesias. Dykinesia is an involuntary movement that can affect the head, shoulders, arms and legs. The development of dyskinesia is related to the amount and duration of use of Sinemet.

Another new medication that was approved by the FDA is a drug called Azilect (Rasagiline.) This is in the class of medications known as the MAO-B inhibitors. MAO is a an enzyme in the body that breaks down dopamine. By inhibiting MAO-B, Azilect allows more dopamine to enter the brain. It also theoretically slows the breakdown of dopamine. Dopamine is the main brain chemical transmitter that is lacking in Parkinson patients. This drug can be used by itself or in combination with other Parkinson medications, particularly levodopa (Sinemet.) Unfortunately, like other Parkinson drugs, Azilect does not work for everyone.


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