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Major report calls for better nurse training in dementia care

A “significant improvement” is needed in the way hospitals deliver care to people with dementia, according to a major national report.

While hospitals say they have policies in place, these are not always followed and simple steps are not taken that could lessen the distress to patients, most of whom are elderly.

The study said the encounter between staff and patients “is mainly task-related and delivered in a largely impersonal manner”, while the hospital environment is “often impersonal”.

Staff do not always greet or talk to patients during care, explaining what they were doing or offering choice. Sometimes they do not respond to patient requests for help.

The National Audit of Dementia, which covers England and Wales, found only 6% of people with dementia had their level of cognitive impairment measured on admission and discharge, while only 43% of case notes showed patients had a mental status test despite 75% of hospitals saying they had a procedure for it.

Only 9% of case notes showed patients being screened for delirium, despite 33% of hospitals saying they had policies in place.

People with dementia can become agitated, distressed or aggressive while in hospital due to the hospital environment, aspects of care, illness or injury, or their dementia getting worse.

NHS guidance says the use of antipsychotics to control these symptoms should be a last resort, but many hospitals still use them.

The audit found 28% of people with dementia received antipsychotic medication in the hospital, of which 12% were newly-prescribed the drugs while in there.

The reasons for these prescriptions were not recorded in 18% of these cases, while less than half of staff felt properly trained in dealing with challenging behaviour.

More than half (59%) of wards said personal items (such as family photographs or cards) were not put where dementia patients could see them for reassurance.

And only 26% of casenotes showed an assessment of functioning (such as basic activities of daily living, activity/exercise status, gait and balance), despite it being included in 84% of hospital procedures.

While 96% of hospital policies said they assessed nutritional status, only 70% of casenotes showed this had been done.

Furthermore, 19% of casenotes did not show the patient was asked about any continence needs and 24% did not show that the patient was asked about pain.

Only 74% of wards had a system to ensure enough staff to help dementia patients eat at mealtimes and only 5% of hospitals had mandatory training in awareness of dementia for all staff.

Overall, less than a third (32%) of staff said they had sufficient training or learning in dementia care.

Recommendations in the report include providing basic dementia training for all staff, with some ward staff receiving higher level training.

A senior clinical lead for dementia should also be in place in each hospital, with dementia champions in each department and at ward level.

Responding to the report, Royal College of Nursing chief executive and general secretary Peter Carter, said: “It is extremely worrying that two thirds of staff found that their training and development was not sufficient. It is essential that all staff are supported through training, education and leadership so that they able to provide skilled, knowledgeable care to people with dementia.

“Equally, each nurse is personally accountable for their own practice and must act promptly to raise concerns if staffing levels or other pressures are getting in the way of delivering good care,” he added.

Alzheimer’s Society chief executive Jeremy Hughes said: “Given that people with dementia occupy a quarter of hospital beds and that many leave in worse health than when they were admitted, it is unacceptable that training in dementia care is not the norm. Staff want to be empowered with the tools they need to deliver good quality care to people with dementia.

“Being in hospital is often confusing and frightening for people with dementia, but small changes can help make their stay more comfortable. We also need to invest in community care to support people with dementia to live at home and prevent them going into hospital unnecessarily.”

 

Readers' comments (14)

  • Once again it is interesting to note the use of the word 'nurse' when bashing staff. No mention of poorly trained doctors or other staff when dealing with dementia.
    Some sufferers of dementia(very confused) gladly acquire any photo they can lay their hands on, and of course the control and infection team frown upon such behaviour,though you cannot be seen to lock individual rooms , as this can infringe on privacy.
    Again an article that simplifies the situation. Yes all staff working with dementia need more training, resources. There needs to be more education about the issues surrounding challenging behaviour in dementia and the difficulties this can present.Some desk staff are really out of touch with the day to day reality of attempting to understand the complexities of caring for a number of confused patients in a confined environment.

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  • “The study said the encounter between staff and patients “is mainly task-related and delivered in a largely impersonal manner”, while the hospital environment is “often impersonal”.”

    WHY?

    “Staff do not always greet or talk to patients during care, explaining what they were doing or offering choice. Sometimes they do not respond to patient requests for help.”

    WHY?

    “People with dementia can become agitated, distressed or aggressive while in hospital due to the hospital environment, aspects of care, illness or injury, or their dementia getting worse.”

    AND DISORIENTATED. OBVIOUSLY, THESE ARE ALL SYMPTOMS OF DEMENTIA.

    “NHS guidance says the use of antipsychotics to control these symptoms should be a last resort, but many hospitals still use them.”
    WHY?

    “Only 74% of wards had a system to ensure enough staff to help dementia patients eat at mealtimes and only 5% of hospitals had mandatory training in awareness of dementia for all staff.”
    WHY?

    “Overall, less than a third (32%) of staff said they had sufficient training or learning in dementia care.”

    WHY?



    “Recommendations in the report include providing basic dementia training for all staff, with some ward staff receiving higher level training.”
    When I qualified in the mid-80s care of the elderly and those with dementia was included in training with assignments on geriatric and psycho-geriatric wards.
    When I worked in a rehabilitation clinic we were given further and more in-depth training in dementia which provided a useful insight into this group of disorders and identifying and meeting the needs of patients with this group of disorders.
    There are different types of dementia of which Alzheimer’s is one type. Although most common in the elderly, dementia can also occur in younger individuals. I looked after two in their 40s both diagnosed with Alzheimer’s. One was a female dentist with an advanced form who I looked after in psycho-geriatrics where her husband also supported her during much of the day. The other was a male patient, on a general medical and mental health ward of a rehabilitation clinic for medical or surgical patients after discharge from hospital and mental health patients with problems such as severe depression or burnout who did not wish the stigma of being hospitalised for these disorders. This was the reason that this patient came to us.
    It was quickly seen that this open ward with single or double rooms was not suitable for a patient with advanced Alzheirmers as he was totally disorientated and wandered off. With one staff member on duty at certain hours, and especially at weekends when there were fewer staff in the clinic, it was impossible to attend to him and to other patients as well although as usual the response from management was that it was up to us to manage our work properly! A very convenient response from those who are totally out of touch with work on the wards. It was a constant concern for the staff who needed to know where he was at all times. One day he was eventually found in a café with a bottle of red wine in front of him. Staff had had to go out in their cars at lunch time searching for him! Fortunately it was a time when there were several on duty.
    At the weekend when I was alone on the ward I had to go and help an elderly lady to the bathroom and change her pampers which obviously took quite a few minutes. I had to ask him to wait outside and left the door ajar. I knew he didn’t really understand and one couldn’t reason with him (sometimes it worked for a few minutes) but I didn’t see any other options the lady was unable to wait and I didn’t want the risk of her falling. After a few minutes he came into the bathroom much to the wrath of this lady’s husband against me and no explanations were acceptable to him. I really did understand his point and was very uncomfortable about it but my duty was towards the duty of both patients and at the same time!

    When I needed to go to the loo myself (having waited as long as I possibly could!) I phoned a colleague on the floor just upstairs, the nearest ward, and was delivered a very severe lecture by her of her responsibilities and not being able to leave the ward for five minutes. She was right too but fortunately she did come down (just before it was too late!) but was extremely angry with me which didn’t help me very much as a newcomer trying to make some sort of impression.
    Fortunately other staff spoke with the doctors and managers and it was agreed on the Monday to move this patient to a centre specialised in dementia.
    This is to illustrate that these patients, depending on the severity and advancement of their disorder, often need one to one nursing care and a general medical ward where other patients often need urgent attention and care, and with limited staffing, is not always a suitable place for them.
    Even in old people’s homes where several residents need care at the same time, and limited staff, it is difficult to deal with one or more patients with dementia who are able to do little for themselves, who may be agitated, who do not understand explanations or that they are being asked to wait and who have a propensity to wander off.
    With the training I received I find it helpful in gaining some insight into patients with dementia and their needs and possibly sufficient for looking after a single patient on a general ward but consider it is a field which needs highly trained and specialist staff in purpose built facilities in order to look this group of patients/clients/residents successfully.
    “A senior clinical lead for dementia should also be in place in each hospital, with dementia champions in each department and at ward level.”
    I find this an excellent idea but think it is one thing having patients with dementia in hospital for medical and surgical reasons or possibly to carry out an assessment and diagnose dementia (in a specialised unit for this group of disorders or for care of the elderly) but I do not think dementia should be a reason for hospitalisation where more suitable facilities are required where patients are supported to carry on as far as they are able with their own daily living functions. Most are capable of quite a lot and should not be left in bed, in a chair or to their own devices all day long unless it is clear this is what they and their families want. Prolonged hospitalisation may exacerbate disorientation in patients with dementia and may accelerate deterioration and further loss of function which it is important to try and preserve for as long as possible.

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  • michael stone

    Anonymous | 17-Dec-2011 9:58 am

    Everything you have posted seems 'likely to be spot-on' to me - however, as itis well-known in NT circles that I am almost invariably wrong in my opinions (because I am not a nurse, so all of my beliefs MUST De Facto be flawed) I can only conclude that you are actually wrong.

    Doesn't this come down to both of the things which are usually the answer (sometimes only one is necessary, but here 2) to most NHS problems ?

    1 Better training and 'systems' (ie where dementia patients are placed within the system)

    2 Enough staff to cope

    But 2 costs money, and 1 might cost money (it could save money) depending on how effective the changes are, versus how extensive the training/system changes are.

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  • michael stone | 17-Dec-2011 12:19 pm
    from
    Anonymous | 17-Dec-2011 9:58 am

    my post concerns providing humane care of the best specialist quality to the elderly and those with dementia it is not concerned with money.
    I speak from the experience of long years of working in functioning systems and witnessing systems which are actually still successful because training keeps abreast with increasing knowledge of these disorders and their management and if we wish to restore and provide adequate care in the future perhaps we should be looking at examples of systems which are more highly effective. We need to consider that in the future there will be more elderly possibly requiring such care and possibly increasing numbers of people with dementia. A thorough understanding of the different types of dementia and how to care for this group of patients is required and as I said above if they are totally disorientated, delusional or agitated without adequate staff to supervise them they are practically impossible to manage on a general ward and it does them a serious disservice which can have potentially fatal consequences.

    In general hospital care it would do little harm for those involved with healthcare at all levels of the hierarchy to look to Germany, Switzerland and possibly France to see how they take their jobs as professionals seriously. Perhaps it would not be a waste of this money that has been misspent or that we don't have to send some staff on tours to these and other countries to learn for themselves.

    Or are we going to continue excluding some groups of patients in favour of others under the pretext of a lack of funds to provide adequate staffing and specialist training. This tale is getting a little stale especially when it starts to affect people in your care, your nearest and dearest or even yourself!

    For one of the richest countries in the world it is a scandal that the elderly are not being provided with adequate care and this means even one single individual.

    It is a scandal that many of those responsible for their care are not adequately trained and it is appalling that we have enough finances to support the private and financial sectors which make up the minority of workers in our population but not the majority who now work in the service sector, and usually for longer hours and under often very difficult conditions to support them!

    we are not talking about philosophy here, nor some weird logic or fantasies but reality and individual and sacrosanct human lives and it is only those who work with these groups of patients who are in possession of the full facts of their very special and specific needs and the needs of those looking after them.

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  • tinkerbell

    Anonymous | 17-Dec-2011 9:42 pm

    Our NHS unit is a specialist, mixed sex, inpatient dementia unit for the severely cognitively impaired with complex needs, and as you say this is a very specialist and specific. We nurse patients who cannot be placed anywhere else because their behaviours cannot be managed, as they usually present with challenging, aggressive behaviours. The client group is getting younger it appears from my experience.

    I am assuming that patients with dementia admitted to a general ward have been admitted with a diagnosis of dementia already in place and have a physical illness that has brought them onto a general ward that needs to be addressed. Dementia patients with a UTI infection for example may also have a toxic confusional state which exacerbates their dementia and until this is resolved may be harder to manage. Then there are the falls, broken hips etc., It also all depends on the severity of their dementia, whether it is mild, moderate or severe, someone with a UTI who previously had a mild to moderate dementia could present as severe. Elimination of a physical cause is always the first rule of psychiatry. We always treat any physical complication as best we can on our unit, but sometimes acute conditions need to go to a general hospital for treatment. I don't think general wards are able to cope with the demands of a disruptive dementia patient but cope as best they can, and mostly they do the best they can for our patients whilst they are in their care. Education in dementia is fundamentally required to have a better understanding but specialist input is totally required. From the outside looking into our unit we would appear to be in daily chaos, but dementia is a chaotic condition and we enter into the reality of our patients condition rather than unrealistically expecting them to enter into ours. This requires we see the meaning behind the words and the feelings behind the words, as words become less important and the meaning behind the words and the behaviour and non verbal cues become more important our clues. We try wherever possible to have the 'life story' of our patients so that we can relate to where they may be coming from and the moment in time they are living or re-living.

    A general ward is as it says a general ward and not specialist in dementia but i would at least expect that every clinician has some education in dementia but it is vital that they can call on specialist knowledge. It would be impossible to educate someone in a day/week/month with all the knowledge that is required on how brain damage to specific parts of the brain affect behaviours. As our consultant said 'you see one dementia patient, you see one dementia patient'. Everybodys presentation will be unique. Although different types of dementia may present in different ways it is always the person behind the illness that we are ryring to connect with. It is a wonderful moment when you make that connection at some deep level which may be only fleeting but so rewarding.

    As none of us know how we will end up or who will be able to care for us in the future we are daily reminded that ultimately that could be us and hope that the NHS will still be there to provide the quality care our loved ones or we ourselves need. It keeps us very grounded.

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  • tinkerbell | 18-Dec-2011 12:03 pm

    from Anonymous | 17-Dec-2011 9:42 pm

    an excellent and very lucid post Tinkerbell.

    I have just responded and thought I should transfer it to MS Word and then paste it, as I sometimes do with more important or longer comments, but just as I decided I had almost finished I lost this page! Although I was already signed in I got another page telling me to sign in as there was a problem with my account. I think the problem is actually the very small keyboard on my notebook and I tend to lean on some of the keys whilst typing, as it is not the first time it has happened.

    May try again later this evening if I have the courage with a bad cold to start all over again and can still remember what I said!

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  • tinkerbell

    Anonymous | 18-Dec-2011 1:43 pm

    Many thanks. Get well soon:)

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  • For those of us with a research interest in dementia and dementia care this is REALLY not new OR NEWS.. alot of this is well written by authors

    the facts are that traditional education alone will not lead to sustained changes in practice; a whole systems approach needs to be adopted in improving dementia care, from understanding organisational and team culture; to exploring environmental factors(such as noisy environments); unfortunately this means money...and who has the budget..???


    A basic review of the literature shows that there has been a tremendous amount of work invested in understanding dementia, understanding the nursing needs of dementia patients and developing models of care delivery such as Kitwoods (1997) person-centred approach model.

    What is also interesting is that with all this ‘knowledge’ derived from research evidence, frontline nursing staff have expressed that they are ill –prepared and do not have the ‘knowledge’ and skills to meet the needs of dementia. Some efforts have been made to address this, for example, the Let’s Respect campaign (National Mental Health Development Unit 2009), and other research publications and studies focusing on the skills and knowledge that nursing staff require to meet the needs of dementia patients (Pritchard and Dewing 2001, Archibald 2003, Norman 2003); as well as organisational guidance from public documents from the Department of Health(2003,2009a,2009c) and expert advice from the National Institute of Clinical Excellence and Social Care Institute of Excellence (2006). Following on from this there has been a growing voice- suggesting that providing dementia training is the solution to fill the knowledge gap (Sheard 2009).

    The question to answer is whether a dementia training and development is enough to improve dementia nursing care.
    we know that while awareness raising training has it part to play in growing individual skills in dementia care; its impact is limited. Through heightened awareness staff may be able to change moments in people’s lives, but it is organisational leaders and skilled team changes that are needed to change whole care cultures. It is clear that training that is not centred on an organisations vision, strategy leadership and team work will always flounder; it can feel easier for organisations to keep churning out safe topic based training. Even then, evidence suggests that available training and access to it are variable and not necessarily provided by staff experienced in dementia care.
    The future of dementia training has to lie in its ability to show evidence that peoples lived experience in care setting has improved. It requires a different sort of leaning and development which avoids tick box training. The dementia knowledge derived from research; needs to be in a format that is useful and workable for frontline staff

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  • colorful, soft and touchable items help to calm the ,position of Individual who has dementia as white has No depth reception , a Brain Gel from journal of compound is a good combatant to stop in track but not reverse dementia . it is best to have a routine daily , and to create a bus stop atmosphere in community walking is good and allot times people need nutrition to think well,.

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  • michael stone

    Anonymous | 17-Dec-2011 9:42 pm

    I am 100% with you, in our mutual belief that the elderly deserve humane care (everyone does, but perhaps the elderly even more so) but this does, in part, come down to money. I agree that in an ideal world money would not come into it, but the NHS does not spend an unlimited amount of money.

    Making a case for more spending is a legitimate political 'campaign', but you actually have, at any one time, only what you have managed to get. So, I can refer to a definition of an engineer: 'An engineer can do for a penny, what any fool can do for a pound'.

    In other words, part of the solution in the real world, is to discover how to best spread 'best practice' once that best practice has been identified: clearly specialists in dementia care, are well-placed to help identify best-practice.

    But your own example, of a situation when you were 'overwhelmed by the situation of having too many patients to cope with', can only be remedied by providing enough staff to cope: managers are often trying to reduce staff, not increase staffing levels.

    That report also seemed to imply that even some nurses, somehow think that demented people 'are being deliberately awkward'. I had some very limited experience of my mum 'being elsewhere/deluded' as she was dying, and based on that very limited experience, it seemed to me that this 'early dementia' (which I guess is the next along from 'forgetting my husband is dead, or where I live, etc) isn't in any sense 'awkwardness' - it is confusion. The person's brain has been deprived of a lot of the 'background information' it uses to make a mental pattern of the world, and using what it does 'know', combined with what it sees, the person comes up with an interpretation of the world which is confusing and scary !

    This is off topic, but it struck me as my mum lapsed towards her death. I had assumed that 'periods of being elsewhere' were effectively the 'same person in the now, but missing some recentish events'. But I decided, for my mum, that it wasn't like that. It seemed as if, somehow here mind had reverted to an earlier 'time setting' in its internal beliefs. So, it wasn't as if my 86 yr old mum had forgotten that my dad had died, and that she no longer lived in her childhood home. It was as if her mind had 'reverted' to an earlier stage of her life - as if she had the 'mind and knowledge' she would have had when she was perhaps 65 yrs old, and what she was 'seeing around her' was being fitted to that 'legacy' 'belief set'.

    If I had my 'mind' from 20 years ago when I woke up one morning, then on looking at the world, I would be enormously confused - so, I am wondering if a huge part of the behaviour of dementia patients, is down to that sort of confusion ?

    I also noticed that my mum did some very strange things (folding things, ripping paper up and making small piles of the pieces) which to me, look like 'pattern-checking behaviour'. I think she was losing brain areas (I suspect via small strokes) and I feel sure that much of the work our minds do is 'pattern creation', to create our 'internally consistent belief set, within which we fit our experiences' - so I think that particular behaviour, was my mum's brain 'realising it was damaged, and looking to repair the damage' in some way (by 'pattern creation' for the folding and pile formation behaviours).

    I'm getting too philosophical, so I'll stop here !

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  • Dementia care: the inside story
    Dr Max Pemberton recalls the casual neglect – and moments of inspired nursing – he witnessed while working in care homes for the elderly.

    Dr Max Pemberton has witnessed dementia sufferers being abused but he has also seen nurses demonstrate great care and insight

    http://www.telegraph.co.uk/health/elderhealth/8684743/Dementia-care-the-inside-story.html

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  • "That report also seemed to imply that even some nurses, somehow think that demented people 'are being deliberately awkward'."

    i am not sure whether you are referring to the article or my comment but I can assure you that in the clinic where I worked we adequatly trained in mental health to recognise and manage a wide range of psychopathologies and would never consider a patient with a MH disorder or any of the dementias as 'deliberately awkward'. It was just unfortunate that our ward was not suited to the needs and demands of the patient admitted to us. This was an error in the transferal process and agreement among doctors who probably never considered the level of staffing required for this unfortunate patient. I believe that if none of us had had any basic and post grad training in dementia the problematic of this patient for the 48 hours he was with us, before his transfer to more suitable facilities, would have been far greater. Ours was more a problem with staffing levels and the inability to provide the one to one care he required.

    also in response to you comment although I have an MSc in Healthcare Management my role and responsibility was to provide holistic and individualised nursing care to any patient admitted to the ward not to worry about whether or not it was affordable. Although we always had to be aware of and take responsibility for not wasting materials and ordering according to our needs our main duty was to see to it that patients had all they needed for optimal care to be given to them and if this was lacking to justify the necessity and request any extra materials we needed for any patient.

    Managers and administrators, departments of health, politicians, etc are engaged to worry about budgets and are paid a far higher salary than nurses for their efforts!

    I would also query the costs of continuing to include, if this is now lacking and which appears to be the case, basic training in care of the elderly, mental health and the dementias for nurses, medical practitioners and all other healthcare professionals in their training with postgraduate training for those who encounter patients with this disorders in their work.
    I fail to understand how nurses can be on the general register and accept or be accepted in posts in general nursing without this type of training.

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  • michael stone

    Anonymous | 19-Dec-2011 12:37 pm

    My comment was about the report, and its implication that non-specialist nurses might not properly understand dementia, and therefore are perhaps treating patients inappropriately. I was not criticising either you or Tinkerbell, or anyone else who has posted in this discussion - but however expert you are, it strikes me that it is fairly easy to be 'outnumbered' by demented but active patients, which isn't satisfactory but probbaly goes back to my 'it comes down to money' point.

    Some of these problems, do come down to the combination of different roles within the NHS, and the ultimate power of managers, as opposed to front-line staff, to decide about things like staffing numbers and training budgets. I tend to be with anyone who 'puts the patients first' in their mind, while they are thinking about any type of problem - but my instinct, is that a few 'pure pen-pushers' are present in some hospitals, etc.

    It is sheer madness to claim that a clearly inadequate number of nurses can 'cope with too many patients simply by organising their time/behaviour' better !

    But similarly, however many nurses and doctors are present, they do need to properly understand what they would need to do, to do their jobs well.

    Which is what I think tiritega mawaka | 18-Dec-2011 11:06 pm was saying with:

    'the facts are that traditional education alone will not lead to sustained changes in practice; a whole systems approach needs to be adopted in improving dementia care, from understanding organisational and team culture; to exploring environmental factors(such as noisy environments); unfortunately this means money...and who has the budget..???'



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  • dementia care is an important topic on everybody's lips but i do get fed up when nursing staff are blamed for everything that goes wrong these days, yes dementia patients do supply some challenging behaviour and very often we are so rushed off our feet just tagging them because they are not able to be left by themselves at any one time, Having more staff at these times would be an ideal and is not the norm especially because other areas may not be well staffed and these are taken away, so unfortunately it puts us back to square one. Most of the time the staff pull their hair out when we are not able to do our job properly and look after the groups of patients' we are allocated. Please don't put the nursing staff down give us encouragement and assistance to enable us to do our job properly and look after all groups of patients not just specific groups, after all we have a duty of care to all that are allocated to us.
    I've properly gone of the tack but although i know dementia patients are important i also recognise that so are all my other patients, being a nurse for the older adult there is a high percentage that my patients fall into this category but not all, but most need assistance with washing and dressing, feeding and assistance with walking, so give us a break from blame for five minutes. PLEASE

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