- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT01670825
Pulsed Radiofrequency vs. Steroid Injections for Occipital Neuralgia
Randomized, Double-blind, Comparative-effectiveness Study Comparing Corticosteroid Injections to Pulsed Radiofrequency for Occipital Neuralgia
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
Up to 76 patients referred to one of the participating pain clinic with occipital neuralgia, or migraines with occipital nerve tenderness (dual diagnoses) will be randomized in a 1:1 ratio by a computer generated randomization table to receive one of two treatments. Treatments will be randomized at each institution. Within each group, those patients with plain occipital neuralgia, and those with occipital neuralgia with migraines, will be sub-randomized in the same 1:1 ratio. Diagnosis of ON will be made by low-volume (< 3 mL bupivacaine per nerve). Our criterion for a positive response will be > 50% pain relief lasting at least 3 hours. Those individuals who have symptoms in the distribution of both the greater and lesser occipital nerves will receive treatment of both nerves. The greater occipital nerve is more frequently affected than the lesser nerve.
Half (n=38) of the patients will be allocated to receive local anesthetic & corticosteroid injections at each nerve (group I), with an equal number allocated to receive local anesthetic & PRF at each (group II). In those patients who request sedation, an intravenous will be inserted and light sedation administered with low doses of midazolam and fentanyl, in accordance with our standard clinic practice. Treatment in all patients will be accomplished using 20-gauge radiofrequency needles with 10 mm active tips. Prior to treating, electrical stimulation will be performed to ensure ample proximity to the targeted nerve(s), with our target threshold being concordant stimulation at < 0.3 volts at each site.
Once proper needle position is ensured, those in group I will receive an injection at each nerve containing 30 mg of depomethylprednisolone mixed with 2 mL of a 50:50 mixture of 2% lidocaine and 0.5% bupivacaine (2.75 mL). Anywhere between 1 and 4 nerves can be injected, with 4 nerves being targeted if a patient had bilateral lesser and greater occipital nerve involvement. This will be followed by 3 cycles of sham PRF at 120 s per cycle, with slight (approximately 30o electrode adjustments between cycles. For sham PRF, no electrical field or heat is generated (i.e. the machine is not set to any radiofrequency cycle after stimulation), but the cycle times (120 s per cycle) are adhered to (i.e. we will wait a total of 6", 2" per cycle). Those patients in group II will receive injections at each nerve containing 2.75 mL of a solution with 2 mL of 50:50 2% lidocaine and 0.5% bupivacaine + 0.75 mL saline (2.75 mL), followed by 3 cycles of PRF using the following standard settings: voltage output 40-60 V; 2 Hz frequency; 20 ms pulses in a 1-second cycle, 120 second duration per cycle; impedance range between 150 and 400 Ohms; and 42o C plateau temperature.
No patient will be prescribed additional medications or therapy between their procedure and first follow-up. However, they will be allowed to remain on their current, stable analgesic regimen. Rescue medications will consist of tramadol 50 mg 1 to 2 tablets every 6 hours PRN (up to 8/d) and/or acetaminophen or a non-steroidal anti-inflammatory drug such as ibuprofen, diclofenac or ketorolac on an "as needed" basis.
Follow-ups will be performed by a physician blinded to treatment allocation. A preliminary follow-up will be performed at weeks. The first full follow-up visit will be scheduled 6-weeks from the start of treatment. A positive outcome will be defined as a > 50% decrease in headache coupled with a positive satisfaction rating (> 3 on a 0-5 scale). Subjects who obtain a positive outcome at their initial 6-week follow-up visit will remain in the study and return for their 3-month follow-up visit. Those with a negative outcome will exit the study "per protocol" to receive standard care. Subjects who obtain a positive outcome at 1-month but experience a recurrence before their 3-month follow-up visit will also exit the study per protocol, with their final outcome measures recorded before they receive standard care. Those who obtain a positive outcome at 3-months will remain in the study for their final 6-month follow-up, while those who obtain a negative outcome will exit the study. Unblinding for both patients and the treating physician will be after the patient exits the study or after their final follow-up visit for those with continued benefit.
Study Type
Enrollment (Actual)
Phase
- Not Applicable
Contacts and Locations
Study Locations
-
-
Maryland
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Baltimore, Maryland, United States, 21205
- Johns Hopkins
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Bethesda, Maryland, United States, 20889
- Walter Reed National Military Medical Center
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Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- Age greater or equal to 18 years
Occipital neuralgia diagnosed based on history & physical exam and diagnostic local anesthetic blocks, or migraine with occipital nerve(s) tenderness that responds to diagnostic blocks.
a. Greater or equal to 50% relief based on diagnostic local anesthetic block of the greater and/ or lesser occipital nerves that lasts for at least 90 minutes with lidocaine or 3 hours with bupivacaine or ropivacaine 20
- Baseline Numerical Rating Scale average pain score > 4/10
- Frequency of greater or equal to 4/10 pain for at least 10 days per month
Exclusion Criteria:
- Untreated coagulopathy
- Automatic implantable cardiac defibrillator or pacemaker that cannot be temporarily disabled for medical reasons
- Previous pulsed radiofrequency
- Other sources of headache, such as tension-type headache, cervicogenic headache, migraine headache without occipital neuralgia, and other causes (e.g. tumors, congenital abnormalities etc.). Those that can be confused with ON must be excluded based on history and exam (e.g. cervicogenic headaches), symptoms (tension-type headache), response to blocks (all of the above); and lab work (temporal arteritis, which would be confirmed by biopsy after an elevated erythrocyte sedimentation rate).
- Serious medical or uncontrolled or severe psychiatric -
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: Quadruple
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Experimental: Pulsed radiofrequency + local anesthetic injection
Local anesthetic injection plus pulsed radiofrequency over each affected occipital nerve
|
Local anesthetic injection and pulsed radiofrequency treatment x 6 minutes over each affected occipital nerve
Other Names:
|
Active Comparator: Corticosteroid injection + sham pulsed radiofrequency
Injection with corticosteroid and local anesthetic over the occipital nerve(s)plus "sham" pulsed radiofrequency
|
Other Names:
Corticosteroid and local anesthetic injection plus sham pulsed radiofrequency over each affected occipital nerve
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Change in Average Occipital Pain 6 Weeks After the Start of Treatment
Time Frame: From baseline to 6 weeks after the start of treatment
|
The change in the numeric pain scale score from baseline to 6 weeks after treatment.
The scale ranges from 0-10.
The minimum score is 0 which is defined as no pain and the maximum score is 10, which is defined as the worst pain imaginable.
The best possible outcome would be a 0. The worst possible outcome would be a 10.
|
From baseline to 6 weeks after the start of treatment
|
Change in Worst Occipital Pain 6 Weeks After the Start of Treatment
Time Frame: From baseline to 6 weeks after the start of treatment
|
The change in the numeric pain scale score from baseline to 6 weeks after treatment.
The scale ranges from 0-10.
The minimum score is 0 which is defined as no pain and the maximum score is 10, which is defined as the worst pain imaginable.
The best possible outcome would be a 0. The worst possible outcome would be a 10.
|
From baseline to 6 weeks after the start of treatment
|
Change in Average Occipital Pain 6 Months After the Start of Treatment
Time Frame: From baseline to 6 months after the start of treatment
|
The change in the numeric pain scale score from baseline to 6 months after treatment.
The scale ranges from 0-10.
The minimum score is 0 which is defined as no pain and the maximum score is 10, which is defined as the worst pain imaginable.
The best possible outcome would be a 0. The worst possible outcome would be a 10.
|
From baseline to 6 months after the start of treatment
|
Change in Worst Occipital Pain 6 Months After the Start of Treatment
Time Frame: From baseline to 6 months after the start of treatment
|
This outcome measures the change in the numeric pain scale score from baseline to 6 months after treatment.
The scale ranges from 0-10.
The minimum score is 0 which is defined as no pain and the maximum score is 10, which is defined as the worst pain imaginable.
The best possible outcome would be a 0. The worst possible outcome would be a 10.
|
From baseline to 6 months after the start of treatment
|
Change in Average Occipital Pain 3 Months After the Start of Treatment
Time Frame: From baseline to 3 months after the start of treatment
|
This outcome measures the change in the numeric pain scale score from baseline to 3 months after treatment.
The scale ranges from 0-10.
The minimum score is 0 which is defined as no pain and the maximum score is 10, which is defined as the worst pain imaginable.
The best possible outcome would be a 0. The worst possible outcome would be a 10.
|
From baseline to 3 months after the start of treatment
|
Change in Worst Occipital Pain 3 Months After the Start of Treatment
Time Frame: From baseline to 3 months after the start of treatment
|
This outcome measures the change in the numeric pain scale score from baseline to 3 months after treatment.
The scale ranges from 0-10.
The minimum score is 0 which is defined as no pain and the maximum score is 10, which is defined as the worst pain imaginable.
The best possible outcome would be a 0. The worst possible outcome would be a 10.
|
From baseline to 3 months after the start of treatment
|
Change in Average Occipital Pain 2 Weeks After the Start of Treatment
Time Frame: From baseline to 2 weeks after the start of treatment
|
This outcome measures the change in the numeric pain scale score from baseline to 2 weeks after treatment.
The scale ranges from 0-10.
The minimum score is 0 which is defined as no pain and the maximum score is 10, which is defined as the worst pain imaginable.
The best possible outcome would be a 0. The worst possible outcome would be a 10.
|
From baseline to 2 weeks after the start of treatment
|
Change in Worst Occipital Pain 2 Weeks After the Start of Treatment
Time Frame: From baseline to 2 weeks after the start of treatment
|
This outcome measures the change in the numeric pain scale score from baseline to 2 weeks after treatment.
The scale ranges from 0-10.
The minimum score is 0 which is defined as no pain and the maximum score is 10, which is defined as the worst pain imaginable.
The best possible outcome would be a 0. The worst possible outcome would be a 10.
|
From baseline to 2 weeks after the start of treatment
|
Change in Overall Average Headache Pain 2 Weeks After the Start of Treatment
Time Frame: From baseline to 2 weeks after the start of treatment
|
This outcome measures the change in the numeric pain scale score from baseline to 2 weeks after treatment.
The scale ranges from 0-10.
The minimum score is 0 which is defined as no pain and the maximum score is 10, which is defined as the worst pain imaginable.
The best possible outcome would be a 0. The worst possible outcome would be a 10.
|
From baseline to 2 weeks after the start of treatment
|
Change in Overall Worst Headache Pain 2 Weeks After the Start of Treatment
Time Frame: From baseline to 2 weeks after the start of treatment
|
This outcome measures the change in the numeric pain scale score from baseline to 2 weeks after treatment.
The scale ranges from 0-10.
The minimum score is 0 which is defined as no pain and the maximum score is 10, which is defined as the worst pain imaginable.
The best possible outcome would be a 0. The worst possible outcome would be a 10.
|
From baseline to 2 weeks after the start of treatment
|
Change in Overall Average Headache Pain 6 Weeks After the Start of Treatment
Time Frame: From baseline to 6 weeks after the start of treatment
|
This outcome measures the change in the numeric pain scale score from baseline to 6 weeks after treatment.
The scale ranges from 0-10.
The minimum score is 0 which is defined as no pain and the maximum score is 10, which is defined as the worst pain imaginable.
The best possible outcome would be a 0. The worst possible outcome would be a 10.
|
From baseline to 6 weeks after the start of treatment
|
Change in Overall Worst Overall Headache Pain 6 Weeks After the Start of Treatment
Time Frame: From baseline to 6 weeks after the start of treatment
|
This outcome measures the change in the numeric pain scale score from baseline to 6 weeks after treatment.
The scale ranges from 0-10.
The minimum score is 0 which is defined as no pain and the maximum score is 10, which is defined as the worst pain imaginable.
The best possible outcome would be a 0. The worst possible outcome would be a 10.
|
From baseline to 6 weeks after the start of treatment
|
Change in Overall Average Headache Pain 3 Months After the Start of Treatment
Time Frame: From baseline to 3 months after the start of treatment
|
This outcome measures the change in the numeric pain scale score from baseline to 3 months after treatment.
The scale ranges from 0-10.
The minimum score is 0 which is defined as no pain and the maximum score is 10, which is defined as the worst pain imaginable.
The best possible outcome would be a 0. The worst possible outcome would be a 10.
|
From baseline to 3 months after the start of treatment
|
Change in Overall Worst Headache Pain 3 Months After the Start of Treatment
Time Frame: From baseline to 3 months after the start of treatment
|
This outcome measures the change in the numeric pain scale score from baseline to 3 months after treatment.
The scale ranges from 0-10.
The minimum score is 0 which is defined as no pain and the maximum score is 10, which is defined as the worst pain imaginable.
The best possible outcome would be a 0. The worst possible outcome would be a 10.
|
From baseline to 3 months after the start of treatment
|
Change in Overall Average Headache Pain 6 Months After the Start of Treatment
Time Frame: From baseline to 6 months after the start of treatment
|
This outcome measures the change in the numeric pain scale score from baseline to 6 months after treatment.
The scale ranges from 0-10.
The minimum score is 0 which is defined as no pain and the maximum score is 10, which is defined as the worst pain imaginable.
The best possible outcome would be a 0. The worst possible outcome would be a 10.
|
From baseline to 6 months after the start of treatment
|
Change in Overall Worst Headache Pain 6 Months After the Start of Treatment
Time Frame: From baseline to 6 months after the start of treatment
|
This outcome measures the change in the numeric pain scale score from baseline to 6 months after treatment.
The scale ranges from 0-10.
The minimum score is 0 which is defined as no pain and the maximum score is 10, which is defined as the worst pain imaginable.
The best possible outcome would be a 0. The worst possible outcome would be a 10.
|
From baseline to 6 months after the start of treatment
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Change in the Presence of Insomnia 6 Weeks After the Start of Treatment Measured Using the Athens Insomnia Scale.
Time Frame: From baseline to 6 weeks after the start of treatment
|
This outcome will measure the participant's perceived improvement in sleep using the Athens Insomnia Scale.
Scores in this scale can range from 0 to 24. 0 being the best possible outcome and 24 being the worst possible outcome.
A score greater than or equal to 6 indicates a presence of insomnia.
|
From baseline to 6 weeks after the start of treatment
|
Change in the Presence of Insomnia 3 Months After the Start of Treatment Measured Using the Athens Insomnia Scale.
Time Frame: From baseline to 3 months after the start of treatment
|
This outcome will measure the participant's perceived improvement in sleep using the Athens Insomnia Scale.
Scores in this scale can range from 0 to 24. 0 being the best possible outcome and 24 being the worst possible outcome.
A score greater than or equal to 6 indicates a presence of insomnia.
|
From baseline to 3 months after the start of treatment
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Change in the Presence of Insomnia 6 Months After the Start of Treatment Measured Using the Athens Insomnia Scale.
Time Frame: From baseline to 6 months after the start of treatment
|
This outcome will measure the participant's perceived improvement in sleep using the Athens Insomnia Scale.
Scores in this scale can range from 0 to 24. 0 being the best possible outcome and 24 being the worst possible outcome.
A score greater than or equal to 6 indicates a presence of insomnia.
|
From baseline to 6 months after the start of treatment
|
Change in the Severity of Depression 6 Weeks After the Start of Treatment Measured Using the Beck's Depression Inventory
Time Frame: From baseline to 6 weeks after the start of treatment
|
This outcome will measure the change in severity of depression using the Beck's Depression Inventory.
Scores in this inventory can range from 0 to 63. 0 being the best possible outcome and 63 being the worst possible outcome.
A score between 14 and 19 indicates mild depression and a score greater than or equal 29 indicates severe depression.
|
From baseline to 6 weeks after the start of treatment
|
Change in the Severity of Depression 3 Months After the Start of Treatment Measured Using the Beck's Depression Inventory
Time Frame: From baseline to 3 months after the start of treatment
|
This outcome will measure the change in severity of depression using the Beck's Depression Inventory.
Scores in this inventory can range from 0 to 63. 0 being the best possible outcome and 63 being the worst possible outcome.
A score between 14 and 19 indicates mild depression and a score greater than or equal 29 indicates severe depression.
|
From baseline to 3 months after the start of treatment
|
Change in the Severity of Depression 6 Months After the Start of Treatment Measured Using the Beck's Depression Inventory
Time Frame: From baseline to 6 months after the start of treatment
|
This outcome will measure the change in severity of depression using the Beck's Depression Inventory.
Scores in this inventory can range from 0 to 63. 0 being the best possible outcome and 63 being the worst possible outcome.
A score between 14 and 19 indicates mild depression and a score greater than or equal 29 indicates severe depression.
|
From baseline to 6 months after the start of treatment
|
Severe Headache Frequency for Migraine Headaches 6 Weeks After the Start of Treatment Measured Asking the Number of Severe Headaches in the Past Week.
Time Frame: From baseline to 6 weeks after the start of treatment
|
This outcome will measure the number of days the patient has severe migraine headaches in the week (7 days) prior to the 6 week follow-up visit.
A severe headache is defined as a headache with a score greater than or equal to 7 on the numeric pain scale.
|
From baseline to 6 weeks after the start of treatment
|
Severe Headache Frequency for Occipital Neuralgia Headaches 6 Weeks After the Start of Treatment Measured Asking the Number of Severe Headache Days 1 Week Prior to Study Visit
Time Frame: From baseline to 6 weeks after the start of treatment
|
This outcome will measure the number of days the patient has severe occipital neuralgia headaches in the week (7 days) prior to the 6 week follow-up visit.
A severe headache is defined as a headache with a score greater than or equal to 7 on the numeric pain scale.
|
From baseline to 6 weeks after the start of treatment
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Severe Headache Frequency for Migraine Headaches 3 Months After the Start of Treatment Measured Asking the Number of Severe Headache Days 1 Week Prior to Study Visit
Time Frame: From baseline to 3 months after the start of treatment
|
This outcome will measure the number of days the patient has severe migraine headaches in the week (7 days) prior to the 3 month follow-up visit.
A severe headache is defined as a headache with a score greater than or equal to 7 on the numeric pain scale.
|
From baseline to 3 months after the start of treatment
|
Severe Headache Frequency for Occipital Neuralgia Headaches 3 Months After the Start of Treatment Measured Asking the Number of Severe Headache Days 1 Week Prior to Study Visit
Time Frame: 3 months
|
This outcome will measure the number of days the patient has severe occipital neuralgia headaches in the week (7 days) prior to the 6 week follow-up visit.
A severe headache is defined as a headache with a score greater than or equal to 7 on the numeric pain scale.
|
3 months
|
Severe Headache Frequency for Migraine Headaches 6 Months After the Start of Treatment Measured Asking the Number of Severe Headache Days 1 Week Prior to Study Visit
Time Frame: From baseline to 6 months after the start of treatment
|
This outcome will measure the number of days the patient has severe migraine headaches in the week (7 days) prior to the 6 month follow-up visit.
A severe headache is defined as a headache with a score greater than or equal to 7 on the numeric pain scale.
|
From baseline to 6 months after the start of treatment
|
Severe Headache Frequency for Occipital Neuralgia Headaches 6 Months After the Start of Treatment Measured Asking the Number of Severe Headache Days 1 Week Prior to Study Visit
Time Frame: From baseline to 6 months after the start of treatment
|
This outcome will measure the number of days the patient has severe occipital neuralgia headaches in the week (7 days) prior to the 6 week follow-up visit.
A severe headache is defined as a headache with a score greater than or equal to 7 on the numeric pain scale.
|
From baseline to 6 months after the start of treatment
|
Disability Due to Headaches 6 Weeks After the Start of Treatment Measured Using the Headache Impact Scale
Time Frame: From baseline to 6 weeks after the start of treatment
|
This outcome measures what the patient feels they cannot do because headaches.
This outcome is measured using the Headache Impact Test.
Scores in this test range from range from 36 to 78, with higher scores indicating greater negative impact.
A score of less than 50 indicates minimal impact, while a score greater than or equal to 60 indicates headaches are severely impacting one's life.
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From baseline to 6 weeks after the start of treatment
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Disability Due to Headaches 3 Months After the Start of Treatment Measured Using the Headache Impact Scale
Time Frame: From baseline to 3 months after the start of treatment
|
This outcome measures what the patient feels they cannot do because headaches.
This outcome is measured using the Headache Impact Test.
Scores in this test range from range from 36 to 78, with higher scores indicating greater negative impact.
A score of less than 50 indicates minimal impact, while a score greater than or equal to 60 indicates headaches are severely impacting one's life.
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From baseline to 3 months after the start of treatment
|
Disability Due to Headaches 6 Months After the Start of Treatment Measured Using the Headache Impact Scale
Time Frame: From baseline to 6 months after the start of treatment
|
This outcome measures what the patient feels they cannot do because headaches.
This outcome is measured using the Headache Impact Test.
Scores in this test range from range from 36 to 78, with higher scores indicating greater negative impact.
A score of less than 50 indicates minimal impact, while a score greater than or equal to 60 indicates headaches are severely impacting one's life.
|
From baseline to 6 months after the start of treatment
|
Collaborators and Investigators
Publications and helpful links
General Publications
- Huang JH, Galvagno SM Jr, Hameed M, Wilkinson I, Erdek MA, Patel A, Buckenmaier C 3rd, Rosenberg J, Cohen SP. Occipital nerve pulsed radiofrequency treatment: a multi-center study evaluating predictors of outcome. Pain Med. 2012 Apr;13(4):489-97. doi: 10.1111/j.1526-4637.2012.01348.x. Epub 2012 Mar 5.
- Vanelderen P, Rouwette T, De Vooght P, Puylaert M, Heylen R, Vissers K, Van Zundert J. Pulsed radiofrequency for the treatment of occipital neuralgia: a prospective study with 6 months of follow-up. Reg Anesth Pain Med. 2010 Mar-Apr;35(2):148-51. doi: 10.1097/aap.0b013e3181d24713.
- Choi HJ, Oh IH, Choi SK, Lim YJ. Clinical outcomes of pulsed radiofrequency neuromodulation for the treatment of occipital neuralgia. J Korean Neurosurg Soc. 2012 May;51(5):281-5. doi: 10.3340/jkns.2012.51.5.281. Epub 2012 May 31.
- Cohen SP, Peterlin BL, Fulton L, Neely ET, Kurihara C, Gupta A, Mali J, Fu DC, Jacobs MB, Plunkett AR, Verdun AJ, Stojanovic MP, Hanling S, Constantinescu O, White RL, McLean BC, Pasquina PF, Zhao Z. Randomized, double-blind, comparative-effectiveness study comparing pulsed radiofrequency to steroid injections for occipital neuralgia or migraine with occipital nerve tenderness. Pain. 2015 Dec;156(12):2585-2594. doi: 10.1097/j.pain.0000000000000373.
Study record dates
Study Major Dates
Study Start
Primary Completion (Actual)
Study Completion (Actual)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Estimate)
Study Record Updates
Last Update Posted (Actual)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
Other Study ID Numbers
- 373481-3
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
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