Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Myeloid Leukemia


Related Terms

  • Acute Granulocytic Leukemia
  • Acute Myeloblastic Leukemia
  • Acute Myelogenous Leukemia
  • Acute Nonlymphocytic Leukemia
  • Adult Acute Myeloid Leukemia
  • AML
  • ANLL
  • Chronic Granulocytic Leukemia
  • Chronic Myelogenous Leukemia
  • Chronic Myeloid Leukemia
  • CML

Differential Diagnosis

  • AML: Acute lymphoblastic leukemia
  • AML: Agranulocytosis
  • AML: Aplastic anemia
  • AML: Bone marrow failure
  • AML: Chronic myelogenous leukemia
  • AML: Lymphocytic leukemia
  • AML: Lymphoma
  • Both forms: Agnogenic myeloid metaplasia
  • Both forms: Essential thrombocythemia
  • Both forms: Idiopathic myelofibrosis
  • CML: Acute myeloid leukemia
  • CML: Chronic myelomonocytic leukemia
  • CML: Chronic neutrophilic leukemia
  • CML: Leukemoid reaction
  • CML: Myelodysplastic syndrome
  • CML: Myeloproliferative disease
  • CML: Polycythemia vera (PV)

Specialists

  • Clinical Psychologist
  • Hematologist
  • Oncologist
  • Pathologist
  • Psychiatrist

Comorbid Conditions

  • Blood dyscrasias
  • Hepatic disease
  • Immune system disorders

Factors Influencing Duration

Length of disability depends on the type, acuity, and stage of the disease, type of treatment received, response to treatment, side effects from treatment, complications from either the disease or treatment, and the individual's general health status.

Medical Codes

ICD-9-CM:
205.00 - Myeloid Leukemia; Acute; without Mention of Having Achieved Remission; Failed Remission
205.01 - Myeloid Leukemia; Acute; in Remission
205.10 - Myeloid Leukemia; Chronic, Eosinophilic Leukemia, Neutrophilic Leukemia; without Mention of Having Achieved Remission; Failed Remission
205.11 - Myeloid Leukemia; Chronic, Eosinophilic Leukemia, Neutrophilic Leukemia; in Remission
205.20 - Myeloid Leukemia; Subacute; without Mention of Having Achieved Remission; Failed Remission
205.21 - Myeloid Leukemia; Subacute; in Remission
205.30 - Myeloid Leukemia; Myeloid Sarcoma; Chloroma; Granulocytic Sarcoma; without Mention of Having Achieved Remission; Failed Remission
205.31 - Myeloid Leukemia; Myeloid Sarcoma; Chloroma; Granulocytic Sarcoma; IN Remission
205.80 - Myeloid Leukemia; Other Myeloid Leukemia; Aleukemic Leukemia: Granulocytic, Myelogenous, Myeloid; Aleukemic Myelosis; without Mention of Having Achieved Remission; Failed Remission
205.81 - Myeloid Leukemia; Other Myeloid Leukemia; Aleukemic Leukemia: Granulocytic, Myelogenous, Myeloid; Aleukemic Myelosis; in Remission
205.90 - Myeloid Leukemia, Unspecified; without Mention of Having Achieved Remission; Failed Remission
205.91 - Myeloid Leukemia, Unspecified; in Remission

Overview

Myeloid leukemia is a cancer (malignancy) of the bone marrow in which large numbers of abnormal, poorly functioning white blood cells are produced. Myeloid leukemia occurs in two different forms, one that develops slowly (chronic) and one that develops rapidly (acute).

The blood contains three types of cells each of which have special functions: white blood cells (WBCs) are an important part of the immune system and normally fight infection and disease; red blood cells (RBCs) carry oxygen from the lungs to the body's tissues and take carbon dioxide from the tissues back to the lungs; and platelets are part of the complex coagulation mechanism, helping to form blood clots to control bleeding. Under normal conditions, blood cells are produced in an orderly, controlled way as the body needs them. All forms of leukemia are characterized by uncontrolled proliferation of abnormal WBCs.

Myeloid leukemia is linked to a certain type of blood cell (myeloid progenitor) in the bone marrow that is the parent cell for the myeloid line of WBCs (neutrophils, eosinophils, basophils, and monocytes) that each perform a specific function when released into the blood as mature cells. Similarly, a lymphoid progenitor is the parent cell for the lymphoid line of white cells called lymphocytes that proliferate in lymphocytic leukemias. In myeloid leukemia, myeloid progenitor cells in the bone marrow undergo a malignant transformation resulting in accelerated production of poorly differentiated white cells that are not able to carry out their proper functions. These abnormal cells do not mature into the specific cell types but remain as immature cells (myeloblasts); they also do not die as programmed.

In acute myeloid leukemia (AML), the myeloblasts reproduce rapidly and the disease worsens quickly. The rapid proliferation of abnormal myeloid WBCs and their reduced ability to mature and to die normally results in their accumulation in the bone marrow. This can lead to bone marrow failure and the shutting down the marrow's production of normal WBCs, RBCs, and platelets. Symptoms develop and progress rapidly when bone marrow failure reduces the RBC count (anemia), WBC count (neutropenia), and platelet count (thrombocytopenia). The presence of more than 20% immature cells (blasts) in the bone marrow and / or blood confirms the diagnosis of AML (Appelbaum 2215). Leukemic cells carried by the blood also may infiltrate the liver, spleen, skin, and lymph nodes as well as the spine and central nervous system, ovaries, testicles, or kidneys. Pressure from increased cell activity within the bone marrow may result in bone or joint pain. Infection and bleeding also may develop in AML.

Advances in molecular testing have led to various sub-classifications of AML that identify percentages, ratios, and types of malignant cells, along with other factors such as chromosome changes (translocations). These designations aid in determining appropriate treatment for each type of AML.

The newer classification system developed by the World Health Organization (WHO), intended to be clinically useful and to provide meaningful prognostic information, includes four categories of AML: AML with genetic abnormalities, AML with multilineage dysplasia, AML in combination with myelodysplastic syndrome (MDS), and non-classified AML. The older French-American-British (FAB) classification divides the AML in 8 subtypes identified through light microscopy examination and cytogenetic testing of the malignant cells. Each class of AML requires specific forms of therapy (Appelbaum 2215). Identifying the class or subtype of AML can help define the outcome of the disease as favorable, intermediate, or unfavorable.

In chronic myeloid leukemia (CML), proliferation of abnormal WBCs and the development of symptoms occur over a period of years. Because normal cell production and function continue for a longer time, the development of symptoms is slower than the acute form of the disease; 30% to 50% of individuals are without symptoms when CML is diagnosed (Kantarjian). CML is unique among leukemias in that individuals may stay in the chronic phase for many years before the disease progresses.

The diagnosis of CML is confirmed when testing of DNA from bone marrow or peripheral blood cells identifies the Philadelphia chromosome (Ph), a cytogenic abnormality that consists of translocation between chromosome 22 and 9 that leads to fusion of part of the BCR gene from chromosome 22 with the ABL gene on chromosome 9; this abnormal BCR-ABL gene generates a protein of 210 kDa (p210) which has constitutive activity of an enzyme called tyrosine kinase, and several deleterious properties that lead to CML such as ability to prevent apoptosis, speed cell division and inhibit DNA repair, among others. Hence the efficacy in this specific type of cancer of the relatively new targeted inhibitors of tyrosine kinase, such as imatinib and related compounds, that inhibit the activity of the BCR-ABL protein. Philadelphia chromosome is associated with more than 90% of CML cases (Kantarjian 2280). Individuals with CML, as in AML, may develop an enlarged spleen, liver, and gums as abnormal cells proliferate within these organs.

Incidence and Prevalence: About 3 in every 100,000 US citizens develop AML each year (Appelbaum 2215), or about 13,400 individuals (Seiter). CML represents about 15% of all cases of leukemia, with about 1.5 new cases diagnosed per 100,000 population each year, affecting about 5000 individuals (Kantarjian 2279). It is estimated that in the United States by the end of 2013 there will be 14,950 new cases and 10,370 deaths from AML, and 5920 new cases and 610 deaths from CML in both sexes (American).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Abnormal gene expression related to certain chromosome translocations, congenital disorders such as Down syndrome or Klinefelter syndrome, familial syndromes related to gene mutations, and hereditary cancer syndromes such as Li-Fraumeni syndrome, can increase risk of adults developing AML (Seiter). Familial associations do not influence development of CML, but the presence of the Philadelphia chromosome in blood-forming cells (hematopoietic stem cells) of the blood or marrow does predispose individuals to CML (Kantarjian 2280).

Exposure to excessive radiation and to certain chemicals, including benzene, formaldehyde, and petrochemicals, is associated with increased risk of development of AML. Smokers have a small increased risk of developing AML compared to non-smokers (Seiter). Dose-related radiation exposure may increase risk of CML, but no risk for CML has been identified related to benzene or other chemicals (Kantarjian 2280).

Receiving chemotherapy to treat a previous cancer can increase risk of developing AML; for example, in patients with breast cancer who received specific chemotherapeutic agents, AML was diagnosed in 0.2% to 1.0% of patients in the first five years after treatment (Seiter). However, prior treatment of cancer with radiation or chemotherapy does not often influence the development of CML (Kantarjian 2280). Most individuals diagnosed with either type of myeloid leukemia have no identifiable risk factors.

The risk of development of AML increases with age. Older people (median age, 60) are at greater risk of developing acute myeloid leukemia (Appelbaum 2215). Risk of the APL subtype of AML is higher in younger adults (median age 31) and in Hispanics, especially those who have a coagulation disorder (Freireich).

The median age at diagnosis of CML is 55 to 60; only 2.7% of cases are diagnosed in people younger than age 20 (Kantarjian 2279). Males are slightly more likely to develop CML than females (male to female ratio 1.6 to 1) (Kantarjian 2279).

Source: Medical Disability Advisor



Diagnosis

History: An individual with AML may report decreased appetite, unexplained weight loss, fever and headaches. If anemia is present, the reduced numbers of red blood cells and reduced delivery of oxygen to tissues may cause may cause fatigue, paleness, and shortness of breath; a low platelet count may cause unusual bruising or bleeding ; the lack of normal WBCs is associated with recurrent infections, specially of the respiratory tract; other symptoms contingent on infiltration by leukemic cells are swelling or bleeding of the gums, bone and joint pain, blurred vision, difficulty maintaining balance, seizures, and abdominal pain.

An individual with CML may have no symptoms, and abnormal cells may first be discovered in blood tests during a routine checkup. Symptoms, if present, may include night sweats, low-grade fever, chills, other flu-like symptoms, weakness, fatigue, frequent infections, generally feeling ill (malaise), vomiting, loss of appetite, weight loss, easy bleeding and bruising, severe nosebleeds, and swollen or bleeding gums.

An individual with AML or CML also may complain of pain and swelling in the upper left and right quadrants of the abdomen below the ribs where the spleen and liver are located.

Physical exam: Physical findings consistent with anemia, such as pallor and / or a cardiac flow murmur, may be present. Individuals with decreased platelets may have a scattered rash of red dots (petechiae) or larger areas of bruising (ecchymoses) indicating bleeding under the skin. Palpation of the abdomen may reveal areas of swelling indicating liver enlargement (hepatomegaly) and / or spleen enlargement (splenomegaly) due to infiltration of organs by leukemic cells. Fever and other signs of infection, including signs of pneumonia, may be present. Respiratory distress and alterations in mental state may be noted as signs of organ infiltration by leukemic cells.

Tests: A complete blood count (CBC) with differential is performed to determine the numbers of platelets, RBCs, WBCs, and circulating blast cells. Blood chemistry tests including blood urea nitrogen (BUN), creatinine, and lactate dehydrogenase (LDH) usually are done to evaluate kidney and liver function. Measures of the blood's ability to clot (prothrombin time [PT], partial thromboplastin time [PTT]) usually are done if platelets are decreased.

Bone marrow aspiration and biopsy usually are performed to identify marrow cells and confirm the type of leukemia. A sample of bone marrow is removed with a needle (bone marrow aspiration) and examined under the microscope. A bone marrow biopsy, performed with a larger needle, involves removing a small piece of bone and bone marrow together. If leukemia cells are found in the bone marrow, a spinal tap (lumbar puncture) may be performed to check for leukemia cells in the spinal fluid (cerebrospinal fluid).

Cytochemistry techniques may be used to examine cells microscopically after they have been stained using special stains. By highlighting cell characteristics, such as granules or abnormal shapes and sizes, specific types of WBCs can be identified in peripheral blood, bone marrow, spinal fluid, and lymph gland samples to help confirm the diagnosis.

Flow cytometry also may be used to examine cells obtained from the blood, bone marrow, or lymph glands to determine specific characteristics (immunophenotypes) associated with myeloid leukemia. Cytogenetic analysis of the individual's chromosomes may identify abnormalities associated with the diagnosis and prognosis of myeloid leukemia. Genetic abnormalities common in CML (BCR and ABL1 gene mutations) can be detected using fluorescence in situ hybridization (FISH) analysis.

Appropriate testing to determinate the presence of the Philadelphia chromosome (Ph) should be done.

Chest x-rays may be performed to evaluate possible lung or cardiac involvement. Imaging studies such as CT or ultrasound may be used to visualize changes in the kidneys, liver, spleen, or other organs. Multiple gated acquisition (MUGA) scans are performed in individuals with confirmed AML because of a high likelihood of heart problems associated with use of cardiotoxic chemotherapy agents (Seiter). Electrocardiography also may be performed before treatment is recommended.

Source: Medical Disability Advisor



Treatment

Treatment of AML depends on the class of leukemia and consists of chemotherapy and / or a bone marrow transplant (BMT). Combinations of cancer-fighting drugs are used in the treatment of AML, including a first round of therapy (induction therapy) which consists of 3 days of a 15- to 30-minute infusion of the two chemotherapeutic agents combined with a in a 24-hour infusion for 7 days of a third agent. This "3 and 7" therapy requires adequate cardiac, liver and kidney function, and results in remission in about 50% of patients (Seiter, AML). Once remission is achieved, a second round of chemotherapy (called consolidation therapy) is used to prolong remission and improve the chances of cure. Maintenance therapy (or post-remission therapy) follows and may continue for at least 1 year. Autologous hematopoietic cell transplantation (HCT) is sometimes used to improve disease-free survival in younger patients (less than age 60) with AML (Appelbaum 2224). The best results with allogenic HCT are achieved with marrow cells from HLA-matched siblings.

Treatment of CML consists of chemotherapy and sometimes a bone marrow transplant. A targeted drug (imatinib, dasatinib, nilotinib or bosutinib), which inhibits particular tyrosine kinase enzymes in blast cells, instead of an agent that non-specifically inhibits rapidly dividing cells, is used initially to reduce proliferation of leukemic cells. Individuals who cannot tolerate this drug may be given other chemotherapeutic agents such as hydroxyurea and busulfan. In rare cases, radiation treatment to reduce the size of the spleen or removal of the spleen (splenectomy) may help relieve intractable pain. Allogenic stem cell transplantation can be curative for CML, but known risk of treatment-related complications and death often discourages its use, and chemotherapy is still the first choice for achieving remission.

Source: Medical Disability Advisor



Prognosis

The prognosis for individuals with myeloid leukemia (acute and chronic) depends on the stage of the disease at diagnosis. Approximately 25% to 30% of individuals under age 60 with AML survive longer than 5 years (Seiter). About 30% of individuals who undergo transplantation of marrow from HLA-matched siblings will have long-term disease-free survival (Appelbaum 2224).

Historically, most patients with CML have lived for 3 to 5 years after diagnosis. This has improved with the use of targeted drugs, which produce a satisfactory hematologic response in the majority of patients; 89% achieve 5-year survival (Kantarjian 2279). One study showed a 57%, 3-year disease-free survival rate following bone marrow transplants from HLA-matched siblings, but data from other studies indicate CML disease-free survival rates from unrelated bone marrow donors as low as 35% at 2 years, and as high as 57% at 10 years (Kantarjian 2279). Younger patients with CML and those who receive treatment in earlier stages of the leukemia generally have a better prognosis.

Source: Medical Disability Advisor



Complications

Treatment for myeloid leukemia can cause complications such as nausea and vomiting, along with suppression of the immune system that can lead to increased risk for infection and other illnesses. The disease can cause headaches and central nervous system impairment leading to altered mental status. A bone marrow transplant (BMT) has a high risk of treatment-related complications (e.g., heart and / or lung disease, cataracts, problems with other organ systems) and may result in rejection of the foreign tissue, often leading to death.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Time off from work will be required for individuals undergoing chemotherapy, surgery, or other types of treatments for myeloid leukemia. Individuals who receive a bone marrow transplant (BMT) may be unable to return to work for a prolonged period. Other individuals may require reassignment to duties with more sedentary work requirements to relieve fatigue and physical stress caused by both the condition and treatments. Company policy on medication usage should be reviewed to determine if prescribed medication use is compatible with job safety and function.

For more information on risk, capacity, and tolerance, refer to "Work Ability and Return to Work," pages 406-407.

Risk: No job places an individual at risk of cancer recurrence. However, if an individual is immunocompromised while recovering, he or she should not return to work with high public contact or working with jail or indigent patient populations.

Capacity: Capacity can be measured using Stress ECHO and PFTs to ensure adequate reserve for return to work.

Tolerance: Tolerance will be affected by lingering effects of chemotherapy trials and / or radiation as these lead to fatigue, memory and concentration difficulties. Multiple medications, blood monitoring, and doctor visits dominate the clinical picture and practical time of an individual. Ideally, reduced work hours may accommodate that limitation while creating a permissive environment of eventual return to work.

Source: Medical Disability Advisor



Maximum Medical Improvement

Patients undergoing chemotherapy are not at MMI until 90 days post chemo.

Patients who are on maintenance chemo, as seen in some chronic conditions, would be at MMI at 90 days.

Patients who require surgery only would be at MMI at 90 days.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Has individual experienced unexplained headaches, weight loss, weakness, malaise, and / or fatigue?
  • Does individual have night sweats, fever, chills, other flu-like symptoms, frequent infections, vomiting, loss of appetite, or general malaise?
  • Does individual show signs of abnormal bleeding or unusual bruising, nosebleeds, and swollen or bleeding gums?
  • Has individual experienced slow recovery from infections and other diseases?
  • Has diagnosis been confirmed through a complete blood count (CBC), blood chemistry studies, flow cytometry, cytogenetic analysis, FISH analysis, or other appropriate testing?
  • Has a chronic or acute form of myeloid leukemia been confirmed by biopsy?
  • Have other conditions with similar symptoms been ruled out?

Regarding treatment:

  • Has individual with AML received combination chemotherapy (AML)? Has individual with CML received chemotherapy involving a targeted drug (imatinib, dasatinib, nilotinib, or bosutinib) or other agents (CML)?
  • After first remission in AML, was consolidation therapy used to prolong remission and improve the chances of cure? Was it followed by maintenance therapy?
  • Does individual require additional treatment such as removal of the spleen (splenectomy)?
  • Is individual a candidate for a bone marrow transplant (BMT)?
  • Have leukemic cells infiltrated other organ systems? If so, are appropriate treatments being considered and / or applied to address the spread of cancer?

Regarding prognosis:

  • Was condition discovered early enough for treatment to be more effective?
  • Is individual older than age 60?
  • Was initial treatment for individual effective, or were additional therapies needed?
  • Was remission achieved? Has individual experienced relapse after remission?
  • Have leukemic cells infiltrated other organ systems?
  • Did individual experience complications from bone marrow transplant (BMT), chemotherapy, or other treatments? How are complications being managed?
  • If individual required a BMT, was a matched sibling available as a donor?
  • Has individual experienced frequent infections due to immunosuppression? Are precautions being taken to avoid infection?
  • Has individual's mental status been affected?

Source: Medical Disability Advisor



References

Cited

American Cancer Society. "Cancer Facts & Figures." American Cancer Society. 25 Apr. 2013 <http://www.cancer.org>.

Appelbaum, Frederick R. "Acute Myeloid Leukemia in Adults." Clinical Oncology. Eds. Martin D. Abeloff, et al. 4th ed. Churchill Livingstone Elsevier, 2008. 2215-2230. MD Consult. Elsevier, Inc. 3 Jun. 2013 <http://home.mdconsult.com>.

Freireich, Emil J. "Acute Leukemia." The Merck Manual of Diagnosis and Therapy. Eds. Robert S. Porter, et al. 18th ed. Whitehouse Station, NJ: Merck and Company, Inc., 2008. The Merck Manuals. Jul. 2012. Merck & Co., Inc. 3 Jun. 2013 <http://www.merck.com/mmpe/sec11/ch142/ch142b.html >.

Kantarjian, Hagop, et al. "Chronic Myeloid Leukemia." Clinical Oncology. Eds. Martin D. Abeloff, et al. 4th ed. Churchill Livingstone Elsevier, 2008. 2279-2289. MD Consult. Elsevier, Inc. <http://home.mdconsult.com>.

Seiter, Karen. "Acute Myelogenous Leukemia." eMedicine. Eds. Clarence Sarkodee-Aloo, et al. 9 Mar. 2012. Medscape. 3 Jun. 2013 <http://emedicine.medscape.com/article/197802-overview>.

Talmage, J. B. , J. M. Melhorn, and M. H. Hyman, eds. Work Ability and Return to Work, AMA Guides to the Evaluation of. Second ed. Chicago: AMA Press, 2011.

Source: Medical Disability Advisor






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