Found 372 Results Sorted by Case Date
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California – Family Medicine – Part Ownership Of A Medical Spa With A Nurse Providing Cosmetic Injections



In 2010, a nurse approached a family practitioner with an offer to become a fifty-one percent co-owner and the Medical Director of MedSpa XL, an existing aesthetic practice that provided cosmetic injections to patients.

The nurse, who owned a forty-nine percent interest in MedSpa XL, offered to pay the general practitioner $1,500 per month to review charts and perform good faith examinations of MedSpa XL’s patients by telephone or by Skype.

From 1/1/2011 to 6/30/2012, the family practitioner served as the Medical Director of MedSpa XL.  During this time, the family practitioner was developing her own medical practice and was not on site at MedSpa XL.  The nurse performed the cosmetic injections to MedSpa XL’s patients.

On 5/21/2012, the nurse prescribed and administered Restylane by injection or injections to a MedSpa XL Patient A, and thereby inflicted bodily injury on the patient.

On 6/13/2012, the nurse prescribed and administered Restylane by injection or injections to MedSpa XL Patient B, and thereby inflicted bodily injury on Patient B.

On 5/30/2014, the District Attorney’s Office filed charges against the nurse and the family practitioner.

On 5/30/2014, in the case entitled, The People of the State of California v. [the nurse and the family practitioner], the family practitioner was charged with the violation of Count 3 and Count 6: treating the sick/afflicted without a certificate – conspiring, a felony, as to Patient A and Patient B.

On 10/3/2014, the family practitioner pled nolo contendere to Counts 3 and 6.

On 11/13/2014, the family practitioner’s motion to reduce Counts 3 and 6 from felonies to misdemeanors was granted, and the family practitioner was convicted of Count 3 and Count 6: treating the sick/afflicted without a certificate – conspiring, a misdemeanor, as to Patient A and Patient B.

On 11/13/2014, the family practitioner was sentenced to one year summary probation with terms and conditions, including but not limited to commitment to the Sheriff for 1 day with credit for 1 day of time served and payment of a fine of $245.00.

The family practitioner was placed on probation for five years with stipulations to complete an ethics course, complete 40 hours of free community services,  and to undergo monitoring.  The family practitioner was prohibited from holding any type of ownership interest in more than one medical practice or medical spa.

State: California


Date: September 2016


Specialty: Family Medicine, Plastic Surgery


Symptom: N/A


Diagnosis: N/A


Medical Error: Ethics violation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Pathology – Biopsies Of Patient’s Eleventh, Twelfth, And Thirteenth Thoracic Vertebrae To Evaluate Fractures



On 2/21/2013, a patient had biopsies of his eleventh, twelfth, and thirteenth thoracic vertebrae to evaluate fractures.  On 3/2/2013, a pathologist reviewed the biopsies.  The pathologist provided a diagnosis of no malignancy.  He reviewed slides H and E in making his diagnosis.

In July 2013, slides H and E were sent to an outside laboratory and the outside laboratory determined that the patient suffered from myeloma, a malignant tumor of the bone marrow.  Further immunohistochemistry was conducted which confirmed the diagnosis of myeloma.

The pathologist failed to recognize that a mid to elderly patient with vertebral fractures could be suffering from myeloma and failed to observe the findings on the slides that indicated the presence of myeloma.

Based on this case and others, the Board revoked the pathologist’s license and placed him on probation for 35 months with stipulations that the pathologist complete at least 40 hours of continuing medical education in the areas of deficient practice and undergo monitoring.

The Board restricted the pathologist’s practice in clinical pathology with the terms that the restriction could be put in abeyance once he found a clinical proctor to proctor him on 50 clinical pathology cases.

State: California


Date: September 2016


Specialty: Pathology, Hematology, Internal Medicine


Symptom: N/A


Diagnosis: Cancer, Hematological Disease


Medical Error: False negative


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Pathology – Pathologist Changes Report After Another Reviewing Pathologist Has Different Diagnosis



On 1/7/2014, a patient underwent a needle core biopsy of her right breast and axillary lymph node.  The biopsy was performed at three separate sites, multiple cores were obtained, and the specimens were sent to pathology.

On 1/8/2014, Pathologist A reviewed the three specimens.  Pathologist A provided a diagnosis that the three specimens did not contain cancer.

Following  pathologist’s review, a Pathologist B reviewed the slides and an immunohistochemical stain was obtained, which revealed the presence of cancer.

On 1/21/2014, Pathologist A amended his report to show that cancer was present in two of the three samples he had previously misdiagnosed.

Pathologist A failed to correctly diagnose cancer.  Despite obvious evidence of cancer in the lymph node sample and similar cells present in the breast biopsy, Pathologist A failed to properly diagnose cancer in the samples.

Based on this case and others, the Board placed Pathologist A on probation for 35 months with stipulations that Pathologist A complete at least 40 hours of continuing medical education in the areas of deficient practice and undergo monitoring.

The Board restricted Pathologist A’s practice in clinical pathology with the terms that the restriction could be put in abeyance once he found a clinical proctor to proctor him on 50 clinical pathology cases.

State: California


Date: September 2016


Specialty: Pathology


Symptom: N/A


Diagnosis: Breast Cancer


Medical Error: False negative


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Family Medicine – Patient With Blood Coagulation Disorder Has Anticoagulation Improperly Managed For A Dental Procedure



A patient was diagnosed with a hypercoagulable disorder and was on Coumadin prior to being treated by a family practitioner.

On 1/12/2015, the patient had his INR level checked.  It was noted to be subtherapeutic.  The patient’s Coumadin dosage was increased.  He was advised to have it rechecked in two weeks.

On 1/21/2015, the patient’s dentist requested medical clearance from the family practitioner for dental surgery.  The family practitioner indicated to the dentist that it was acceptable to stop Coumadin six days before surgery, and the patient was given medical clearance.

On 1/29/2015, the patient went to the family practitioner ahead of dental surgery.  The family practitioner discovered that the patient had not yet stopped the Coumadin, even though it should have been stopped two days previously for the upcoming 2/2/2016 scheduled surgery.  The family practitioner then advised the patient to restart the Coumadin the day of the surgery.

The family practitioner never reviewed the patient’s INR levels before the surgery, especially once he knew the Coumadin had not been stopped in time.  The family practitioner never provided bridging therapy, before or after the surgery.

On 2/2/2015, the patient had the dental surgery.  The patient restarted Coumadin on the instructions of the family practitioner.

That afternoon, the patient had bihemispheric strokes resulting in encephalopathy, seizures, and respiratory failure, ultimately leading to death.

An INR level taken in the hospital that evening indicated a non-therapeutic level for a blood clotting disorder.

The Medical Board of Florida judged the family practitioner’s conduct to be below the minimal standard of competence given that he failed to check the INR levels more closely and provide bridging therapy for the blood coagulation disorder.

It was requested that the Medical Board of Florida order one or more of the following penalties for the family practitioner: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Medical Board of Florida deemed appropriate.

State: Florida


Date: September 2016


Specialty: Family Medicine, Internal Medicine


Symptom: N/A


Diagnosis: Ischemic Stroke, Hematological Disease


Medical Error: Improper medication management, Failure to properly monitor patient


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



North Carolina – Internal Medicine – Failure To Follow Up On Abnormal Thyroid Test



In December 2015, the Board received a complaint from a physician who had recently treated one of the patients of an internist.  Specifically, the physician complained that the internist had ordered a thyroid laboratory test and then failed to address the abnormal test results with the patient.

The Board’s investigation revealed that on 09/09/2015, the internist treated a patient.  Due to her symptoms, the internist ordered laboratory tests to assess her thyroid function.  The thyroid studies were significant for hyperthyroidism.  The internist did not inform the patient of the abnormal laboratory test results.

On 09/23/2015, the patient was seen by the internist for other symptoms.  The patient was diagnosed as being pregnant at this visit.  however, the internist again failed to make the patient aware of the abnormal thyroid test results.

On 10/19/2015, the patient was again seen by the internist for urinary tract infection symptoms and again was not informed of the abnormal thyroid test results.

On 11/13/2015, the patient was seen by a different provider who diagnosed her with a heart murmur and a grossly enlarged thyroid.  The patient indicated at this visit that she was unaware of the thyroid test results.

The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.  The independent medical expert judged the internist’s conduct to be below the minimum standard of competence given failure to properly diagnose the patient with hyperthyroidism and failure to recognize the potential harm of hyperthyroidism in a pregnant patient.

The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards and the National Practitioner Data Bank.  The internist was ordered to complete a comprehensive professional assessment in Internal Medicine.

State: North Carolina


Date: September 2016


Specialty: Internal Medicine


Symptom: N/A


Diagnosis: Endocrine Disease


Medical Error: Failure to follow up


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Gynecology – Inappropriate Remarks During Annual Gynecological Examination



On 1/3/2014, a patient presented to a gynecologist for an annual gynecological examination.  During the gynecologist’s examination, of the patient’s breasts, he commented that she had enlarged breasts like “Dolly Parton.”  While the gynecologist was conducting the patient’s pelvic examination, he commented that she “looked like a virgin.” Following the gynecologist’s pelvic examination, he assessed the patient with Candida vaginitis (a yeast infection).

During the course of the Board’s investigation of the patient’s complaint of inappropriate conduct by the gynecologist, the gynecologist admitted that he made the statements to the patient and explained that the “enlarged breasts” comment was to relax and befriend her, and the looked “like a virgin” comment was because she was small and required a small speculum.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because he engaged in sexual innuendo and breached her trust.  The standard of care for breast and pelvic examinations is to inform the patient that she is going to be examined and to obtain her consent.  The standard of care does not include making comments regarding the size of the patient’s breasts or to make comparisons to celebrities or virgins.  The standard of care requires that a practitioner who diagnoses a patient with Candida vaginitis have supporting physical examination evidence of vaginal candidiasis or microscopy to support the diagnosis and that the practitioner counsel the patient regarding the diagnosis.  With respect to the patient, the gynecologist further departed from the standard of care by failing to provide any supporting physical examination evidence of Candida vaginitis or microscopy to support the diagnosis. The gynecologist, when asked to read his progress notes for the patient, had difficulty deciphering his handwriting.

For this case and others, the Medical Board of California placed the gynecologist on probation for 35 months and ordered the gynecologist to complete a medical record keeping course, an education course, a professionalism program (ethics course), and a professionalism boundaries program.  The obstetrician was also prohibited from supervising physician assistants.

State: California


Date: August 2016


Specialty: Gynecology


Symptom: N/A


Diagnosis: N/A


Medical Error: Ethics violation, Diagnostic error, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Obstetrics – Shoulder Impaction With Seven Attempts Using A Vacuum



On 1/9/2010, a patient first presented to an obstetrician for prenatal care.  At that time, the patient was 28 years old, and it was her first pregnancy. Her estimated date of delivery was 6/8/2010.  She presented to the obstetrician’s office for 11 prenatal visits: 1/9/2010, 1/22/2010, 2/19/2010, 3/19/2010, 4/2/2010, 4/7/2010, 5/1/2010, 5/15/2010, 5/21/2010, 5/29/2010, and 6/30/2010.  At each prenatal visit, the patient was examined by the obstetrician and had an obstetrical ultrasound. Her prenatal course was essentially unremarkable without noted risk factors for shoulder dystocia.

On 6/5/2010, at 12:38 a.m., the patient presented to the hospital with an onset of labor.  Examination at 12:46 a.m. revealed that she was 4.0 cm dilated and 90% effaced at -2 station.  Over the next approximate 12 hours, the patient’s labor progressed and at 11:38 p.m., she was 10 cm dilated and 100% effaced at 0 station.  The obstetrician was updated regarding the patient’s status. The obstetrician arrived at the delivery room at 12:10 p.m. Fetal heart rate tracings revealed a baseline heart rate of 140 with moderate variability.  At 12:14 p.m., a prolonged deceleration occurred for approximately 4 minutes with a return to the established baseline for approximately 3 minutes, followed by another prolonged deceleration for 8 minutes. At 12:24 p.m., the patient verbally consented to the use of a vacuum to assist delivery.  The obstetrician’s progress note reflected 4 pulls with the vacuum with no detachments, but video of the delivery shows 7 pulls with the vacuum. The obstetrician encountered an impacted shoulder. The obstetrician stated that there would be a shoulder dystocia, but did not announce it to the entire obstetrical team or call for help.  The patient was in McRoberts position (hips flexed back onto her abdomen to help the baby’s shoulder slip under her pubic bone by enlarging the pelvic outlet), but no suprapubic pressure was applied. The obstetrician rotated the fetal head from occiput anterior (facing down) to occiput posterior (facing up) for suctioning of nares and mouth.  The obstetrician claimed that “[he] felt the axilla on the right arm. And [he] gently retracted on the post axilla, and the arm delivered very easily with the support of the humerus with [his] left index finger.” Video of the delivery showed that the posterior arm was not delivered before the rest of the body, and the obstetrician was seen rotating the head and applying traction to the fetal head and shoulders.  At 12:35 p.m., the obstetrician delivered a 3,262-gram female infant with decreased tone noted in the left arm.

With respect to the documentation of the patient’s labor and delivery, in an undated, untimed, partly illegible, and incomplete, note entitled “MD Progress Note,” the obstetrician documented the vacuum delivery.  A delivery note dated 6/5/2010 and timed at 1:00 p.m. by the obstetrician was absent of documentation of a shoulder dystocia being communicated to the obstetrical team, whether the patient’s analgesia was adequate, and whether or not a pediatrician or a Neonatal Intensive Care Unit team was present in the room.  The note did not reflect which shoulder was impacted nor did it reflect the maneuvers utilized during delivery.

The standard of care for prenatal obstetrical ultrasound is for the practitioner to have ultrasounds performed when there is a valid medical indication.  The obstetrician performed an ultrasound for fetal growth at each of the patient’s prenatal visits without indication. The standard of care for a practitioner encountering a shoulder dystocia at the time of delivery requires that the practitioner alert the entire obstetrical team of a shoulder dystocia, as well as to call for the application of suprapubic pressure while the patient is in the McRobert’s position.  The standard of care further requires attempts at rotational maneuvers before the use of traction of the fetal head and shoulder.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because he performed an ultrasound at each of the patient’s prenatal visits without medical indication, did not announce a shoulder dystocia at the time of delivery, did not apply suprapubic pressure with McRobert’s position, and did not attempt rotational maneuvers before the use of traction of the fetal head and shoulder.

The Medical Board of California placed the obstetrician on probation for 35 months and ordered the obstetrician to complete a medical record keeping course, an education course, a professionalism program (ethics course), and a professionalism boundaries program.  The obstetrician was also prohibited from supervising physician assistants.

State: California


Date: August 2016


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication


Medical Error: Procedural error, Unnecessary or excessive diagnostic tests, Failure of communication with other providers, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



North Carolina – Endocrinology – Concern Raised Over Dosing Of Norditropin For Short Stature



The Board received a complaint regarding the care of a patient.

On 04/03/2013, an 8-year-old boy was referred to an endocrinologist for the evaluation of possible low testosterone.  The boy weighed 20.4 kg and was 46 inches tall.  The endocrinologist examined the patient and noted that he had significant short stature.  He recommended laboratory and radiographic testing in order to develop a definitive plan of care.

On 05/01/2013, the endocrinologist reviewed the patient’s laboratory results with the patient’s parents and explained that the patient’s bone age was approximately 66 months, yet his chronological age was 98 months.  The endocrinologist decided to obtain a growth hormone stimulation test, which was done in June 2013.

On 07/08/2013, the patient presented to the endocrinologist for a follow-up.  The patient weighed 21.1 kg and was 46.5 inches tall.  The endocrinologist reviewed the patient’s laboratory and radiographic results and diagnosed growth hormone deficiency.  The endocrinologist prescribed the growth hormone drug Norditropin (somatropin [rDNA origin] injection).  This treatment involved the patient’s parents injecting the drug Norditropin into the patient’s body.

On 08/16/2013, Norditropin was started on the patient at a dose of 0.6 mg daily (0.23 mg/kg/week).

On 11/27/2013, the patient presented for a follow-up.  The parents mentioned no problems with injecting the Norditropin.  Height was 46.75 inches.  The patient’s Insulin-Like Growth Factor I (“IGF-1”) was 98 ng/ml (normal for this age was 49-351).  The endocrinologist increased the patient’s Norditropin dose to 1.4 mg daily (0.45 mg/kg/week) for one month and then 2 mg daily (0.64 mg/kg/week) until the patient’s next follow-up visit.

On 01/27/2014, the patient presented for a follow-up.  Height was 47.75 inches.  IGF-1 was 146 ng/ml (normal for age was 72-323).  The endocrinologist increased the patient’s Norditropin dose to 3 mg daily (0.9 mg/kg/week).

On 04/07/2014, the patient, now 9 years old, presented for a follow-up.  Height was 48.25 inches and IGF-1 was 210 ng/ml (normal for age was 84-362).  His dose was increased to 4 mg (1.1 mg/kg/week).

On 06/11/2014, the patient presented for a follow-up.  Height was 50 inches and IGF-1 was 203 ng/ml (normal for age was 84-362).  The endocrinologist recommended increasing the Norditropin to 6 mg daily (1.59 mg/kg/week) and wrote prescriptive instructions to that effect.  However, the specialty pharmacy that had been providing the patient’s Norditropin refused to fill the prescription at that dose and the patient never received the 6 mg daily dose.

On 08/06/2014, the patient went to see a pediatric endocrinologist physician who has specialty training and certification in the field of pediatric endocrinology.  This physician lowered the patient’s Norditropin dosage as follows:

“For management of the short stature, I have decreased the growth hormone (Norditropin) to 1.1 mg at night time (0.300 mg/kg/wk as recommended for children with growth hormone deficiency).”

This pediatric endocrinologist treated the patient three months later on 11/3/2014 and noted that he had grown 2 cm (0.79 inches) on the 1.1 mg Norditropin dosage.

The Board obtained the patient’s records and sent them to two qualified independent medical experts for review.  The independent medical experts judged the endocrinologist’s conduct to be below the minimum standard of competence given failure to prescribe the correct Norditropin dosage to the patient.  They did not think the endocrinologist should have increased the dosage based solely on the patient’s IGF-1 levels.  The endocrinologist disagreed with the experts.  The Board notes that the patient was not harmed by the IGF-1, although they acknowledged that there was potential harm if high dose Norditropin therapy is administered in the long term.

The endocrinologist had his care reviewed by three independent medical experts who felt that the care of the endocrinologist was within the standard of care.  One expert wrote that the care of the patient was “evidence-based and follows standard of care.”  One of those experts was the pediatric endocrinologist who lowered the dose of Norditropin from 4 to 1.1 mg.  It is noted that this expert has worked with the endocrinologist over eight years and the endocrinologist referred patients to this expert.  She wrote that her adjustment of the dose “does not imply that [your]dosage was wrong or outside the standard of care” and wrote that the endocrinologist was “a dedicated doctor who provides elite care to his patients.”

The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards.  It was not reported to the National Practitioner Data Bank.

State: North Carolina


Date: August 2016


Specialty: Endocrinology, Pediatrics


Symptom: N/A


Diagnosis: N/A


Medical Error: Improper medication management


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Virginia – Internal Medicine – Prescription Of Oxycodone 30 mg 150 Pills While Patient Obtaining Diazepam From Another Provider



On 4/12/2011, a patient began his treatment at a clinic.  He failed several drug screens.  A note in his medical record indicates that he was called for a pill count on 6/27/2012.  The patient indicated that his medication had been stolen and he had no pills to be counted.

On 11/6/2012, an internist first treated the patient.  He prescribed the patient oxycodone 30 mg, 150 pills.

A patient assessment form from 5/20/2013 is blank as are several other assessment forms in the medical records.  A report from the West Virginia Board of Pharmacy shows that the internist prescribed the same medication to the patient on a monthly basis.  However, the assessment form allowed the patient to request to skip actually seeing the doctor on each visit.

On 7/15/2013, the patient was treated at the clinic.  He requested to skip seeing the doctor.  Other than a check mark indicating “Continue present regimen,” the assessment form is essentially blank.  However, the patient received a prescription written by the internist on this date for oxycodone 30 mg, 150 pills.  The report from the West Virginia Board of Pharmacy indicates that this prescription was intended to last 25 days.

The prescription would indicate that the oxycodone 30 mg would be taken 6 times daily for a total of 180 mg of oxycodone per day.

Medical records for the patient revealed that he was receiving a prescription from another physician for diazepam 10 mg to be taken twice daily.

On 7/18/2013, the patient died from a combination of oxycodone, alprazolam, diazepam, hydroxyzine, and gabapentin intoxication.

The Board expressed concern over the internist’s care of the patient.  During the period that he treated the patient, the internist did not know that the patient had obtained a controlled substance from another physician.

State: Virginia


Date: August 2016


Specialty: Internal Medicine


Symptom: N/A


Diagnosis: Drug Addiction, Drug Overdose, Side Effects, or Withdrawal


Medical Error: Improper medication management


Significant Outcome: Death


Case Rating: 1


Link to Original Case File: Download PDF



Washington – Obstetrics – Single Umbilical Artery With Poor Visualization Of Fetal Heart Structures On Ultrasound



On 6/25/2014, a patient was seen by her obstetrician for a routine prenatal care appointment.  The patient was 37 years old and considered advanced maternal age.  The patient was offered integrated first trimester screening and declined, but did opt for QUAD screening, which is a screening test that may reveal birth defects.  The QUAD screening was negative and the patient did not undergo any additional invasive antenatal testing.

A fetal ultrasound performed on 9/5/2014 showed a two-vessel cord, or Single Umbilical Artery (SUA), and the fetal heart structures were not well seen.  Babies with SUA may have a likelihood of having other congenital abnormalities, especially of the heart; however, additional testing (including high-level ultrasound scans) can help rule out many of these abnormalities prior to birth.  A repeat fetal ultrasound was performed 9/15/2014, but the fetal heart was again not well visualized.  The 10/1/2014 fetal ultrasound showed poor visualization of the right heart structures and the cerebral ventricles were noted to be at the upper level of normal.  The radiologist recommended a maternal fetal medicine evaluation to assess for fetal abnormality.  Chart notes do not indicate that a maternal fetal evaluation was offered or discussed with the patient.

The 10/16/2014 chart note discussed the two-vessel cord and the plan was a growth scan at 32 weeks gestation and weekly fetal non-stress tests (NSTs). On 10/25/2014, a fetal ultrasound was performed, at approximately 32 weeks gestation, and noted normal cardiac outflow.  On 11/3/2014, the patient underwent NST and the test was reportedly normal.

On 10/16/2014, the patient delivered at 35 weeks via Cesarean section due to concerning fetal heart tracings.  Subsequently, it was determined that the baby had Down’s syndrome and a heart defect.

The obstetrician failed to conform to the standard of care when he did not recommend a maternal fetal medicine consult for the patient, in light of various risk factors in this case, including advanced maternal age, ultrasound findings of two-vessel cord, and the difficulty of ascertaining a normal comprehensive fetal survey with multiple ultrasounds.

The Commission stipulated the obstetrician reimburse costs to the Commission and complete 5 credit hours of continuing education on the subject of the management of abnormal findings in high-risk pregnancies.

State: Washington


Date: August 2016


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication


Medical Error: Failure of communication with patient or patient relations


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



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