Same heart attack, same misdiagnosis – but one big difference

4 Feb

by Carolyn Thomas  ♥  @HeartSisters   February 4, 2018

Our two stories are freakishly the same in so many ways:

In 58-year old Nancy Bradley’s story, she went to the Emergency Department at the Royal Inland Hospital near her home in Kamloops as soon as she felt alarming symptoms she knew might be heart-related: dizziness, sweating, shortness of breath and “an elephant sitting on my chest” feeling. (In my story, I was 58 as well, and I went to Emergency at the Royal Jubilee Hospital near my home in Victoria as soon as my own alarming heart attack symptoms started).

All of Nancy’s cardiac diagnostic tests seemed to be “normal”. (All of my diagnostic tests seemed to be “normal”, too).

Nancy’s Emergency physician suspected heartburn, and suggested she take antacid drugs. (My Emergency physician suspected heartburn, and suggested that I take antacids). 

Nancy was sent home, misdiagnosed with acid reflux within five hours of the onset of symptoms. (I was sent home, misdiagnosed with acid reflux within five hours of the onset of my symptoms).

For the next two weeks, when her symptoms flared up, Nancy chewed antacids as directed by that Emergency physician. (For the next two weeks, when my symptoms flared up, I chewed antacids just like the doctor had told me, too).

Two weeks after being misdiagnosed, Nancy finally returned to the same Emergency Department because her symptoms were so bad, she thought she was dying. (Two weeks after I was misdiagnosed, I returned to my Emergency Department because my symptoms were so bad, I thought I was dying).

Each of us learned right away during this second trip to hospital that we were indeed having a heart attack just as we had first suspected, and each of us were immediately admitted for emergency treatment of a 95 per cent blocked coronary artery.

The striking difference: my heart attack happened in 2008, but Nancy’s happened 10 years later.

That makes Nancy’s story so much more disturbing than mine – because it means that, a full decade later, we’re still seeing many female heart patients who are not being diagnosed or treated in the same way our male counterparts are.

It means heart patients like Nancy are still suffering needlessly.

It means that despite study after study, report after report, expert after expert confirming this pervasive cardiology gender gap, the reality remains that when women seek help, they don’t always get it.

One such report launched earlier this week was Ms. Understood, Canada’s Heart and Stroke Foundation’s 2018 Heart Report. The 20-page document, which features Nancy Bradley’s dramatic misdiagnosis and survival story, pulls no punches by summarizing its findings:

“Women’s hearts are victims of a broken system that is ill-equipped to diagnose, treat and support them.”

This conclusion is no surprise to informed physicians, researchers, and patients like me who write about them. It is, apparently, a surprise to many of the journalists who covered the launch of this report on February 1st, as Heart and Stroke Foundation staff told me later that day: “In so many media interviews, journalists are saying what a ‘surprise’  the 2018 Heart Report is!”

(Surprise?!?  These journalists have clearly not been reading either my blog or my book).

Cardiologist Dr. Noel Bairey Merz, Director of the Barbra Streisand Women’s Heart Center at UCLA, bluntly describes this reality for them:

“We are 50 years behind in our knowledge about optimal screening, diagnosis, and treatment regimens for heart disease in women compared to what we know about heart disease in men – and every day, women pay the price.”

The Heart and Stroke report included these highlights (or, more accurately, lowlights):

•Heart disease is the leading cause of premature death for women in Canada.

•Early heart attack signs were missed in 78% of women.
 
•Every 20 minutes a woman in Canada dies from heart
disease.
 
•Five times as many women die from heart disease as
breast cancer.
 
•Two-thirds of heart disease clinical research focuses
only on men.
 
•Women who have a heart attack are more likely to die or
suffer a second heart attack compared to men.
.
The report also describes women’s cardiac care as a “reality defined by unders”:
“Today, when it comes to heart disease, women are under-researched, under-diagnosed and undertreated, under-supported and under-aware.
.
“This complex mix of ‘unders’ began in health research where, for decades, specific therapies were tested in controlled studies on primarily middle-aged, white male subjects. The assumption was that one-size-fits-all.”
That assumption, by the way, includes not just those middle-aged, white male human subjects. Even in animal studies, researchers have used male rats, mice and rabbits in the lab for decades. But you can see what’s been happening: medical decisions made because they seem valid in males (mice or men) end up being applied to women as if we are exactly the same as men. We are not.
.
As cardiologist Dr. Tara Sedlak, director of the Leslie Diamond Women’s Heart Health Centre in Vancouver, wrote in this report:
“Gender bias still exists.
.
“Physicians may look for other causes of a woman’s symptoms, without first doing appropriate tests to rule out cardiac issues. It may not be intentional, yet when there are differences in medical care for men and women across large numbers of patients, it is an indication there is still systemic bias.”

The report also addresses how diagnostic tests are not created equal:

“While no test is 100% accurate, some perform worse for women. The exercise treadmill (or stress) test for cardiac output is far less sensitive for women compared to men, and even worse for younger women compared to older women.
.
“A misleading diagnosis delays early treatment. For heart attack, the key to effectively treating and minimizing irreversible damage is time: open up the arteries quickly, restore blood flow quickly.”
A subject that deserves far more attention is the subject of heart disease in women of South Asian, Chinese or Afro-Caribbean descent, and in Indigenous or First Nations women. This report tells us that they are even more vulnerable to heart disease than we Caucasian women are.
.
For example, Cree heart transplant patient Esther Sanderson reminded the rest of us about this practical reality, especially among those who live in Canada’s North:

“Most First Nations communities do not have a doctor and there are no specialists.

“On-reserve, there are language problems – not only dialect, but also ‘doctor jargon’.  Many people who have been through the residential school experience are hesitant to ask questions of people in authority, so may not understand their condition or medication.
“The health care and treatment at the very beginning of these people’s medical journey is crucial. If that doesn’t work well, they are reluctant to return.
“I believe that the healthcare system can learn from the experience of Indigenous people. We all need the biomedical model to determine a diagnosis, but it is up to us to figure out what will restore our health – within ourselves, our family and our community. We must understand that spiritual, cultural and traditional healing are all important.” 
The 2018 Heart Report contains a number of creative recommendations to combat this gender bias (please read the report to learn more), but until each one is embedded throughout the healthcare system – starting in medical school – will they actually make a difference?
 .
And what can women do for ourselves while we’re waiting around for our assorted healthcare systems to get onboard?
.
Until women decide to:

… then 10 years from now, we’ll still be reading disturbing stories about many more Nancys and Carolyns – and wondering when somebody, somewhere is going to somehow start doing something to help them.

If the tables were turned, if Nancy Bradley and I had been 58-year old men seeking help at our respective Emergency Departments presenting with identical cardiac symptoms, I’m willing to bet my next squirt of nitro spray that males would not be patted on the head and sent home with a little antacid recommendation. Here’s why I believe this:
.

“Consider this story shared with me by a woman attending one of my Heart-Smart Women presentations. While lying on a gurney in the Emergency Department, she overheard this conversation between a physician and one of his (male) patients beyond the curtain separating her from the next bed. The doctor told the (male) patient:

“Your blood tests came back fine, your EKG tests are fine – but we’re going to admit you for observation just to rule out a heart attack”.

“So yet another male patient is thus kept in hospital for observation in spite of his ‘normal’ cardiac test results.”

But Nancy and I and countless other females in mid-heart attack are being sent home from Emergency mistakenly diagnosed with acid reflux or anxiety or menopause or a dog’s breakfast of other popular misdiagnosis options.

As Nancy told the Heart and Stroke Foundation recently:

“I would recommend that women be persistent. You know your own body; a person needs to follow their own gut feeling.

“Looking back, maybe I should have insisted more to the Emergency doctor the first time I went. I knew there was something wrong with my heart. I just knew it.”

NOTE FROM CAROLYN: If you’re an American reading this, and assuming that this new report’s findings are unique to Canada, think again. I’ve been documenting major American reports for years, including these two:

♥ January 2016:   The American Heart Association released its first ever scientific statement on women’s heart attacks (that’s ‘first’ – as in the first one in its entire 92-year history!) confirming that “compared to men, women tend to be under-treated”, and While the most common heart attack symptom is chest pain or discomfort for both sexes, women are more likely to have atypical symptoms such as shortness of breath, nausea or vomiting, and back or jaw pain.”

February 2016: Focused Cardiovascular Care for Women: The Need and Role in Clinical Practice, a report published in the journal, Mayo Clinic Proceedings on why we need Women’s Heart Clinics that can specifically address the many unique considerations of women’s heart disease, concluding: “The public health cost of misdiagnosed or undiagnosed cardiac disease in women is significant.”

Q: What changes do you think would make the biggest difference in closing this cardiology gender gap?

See also:

 

22 Responses to “Same heart attack, same misdiagnosis – but one big difference”

  1. Jiocoin February 9, 2018 at 12:35 am #

    Very good article
    Thank you for sharing – keep up the good work!

    Liked by 1 person

  2. Jennifer Randall Nelson, Heart and Stroke Foundation February 5, 2018 at 11:30 am #

    Thank you for sharing our Heart Report on your blog post. It is wonderful to have your support.

    Thank you.

    Liked by 1 person

    • Carolyn Thomas February 6, 2018 at 9:00 pm #

      You’re welcome, Jennifer. I’m impressed by the range of important issues you and your team cover in this report. Kudos to all of you! I hope we will soon be able to look back on reports about women’s heart health with all of these discouraging stats and remember the ‘bad old days’ that are no more!

      Like

  3. Ellen Agger February 4, 2018 at 8:56 am #

    I guess I was “lucky” that my cardiac event (increasingly unstable angina; not clear to this day if I actually had a heart attack) happened in Chiang Mai, Thailand.

    I got excellent care there, although the Thai cardiologist told me only one blockage was found which was perhaps wrong. The Canadian cardiologist who finally read my Thai angiogram after 3 years said I had 2 additional blockages, not needing stenting. My current cardiologist didn’t even want to see the angiogram (what? they don’t know how to do this kind of medical care anywhere outside North Ameria?)

    I had to push for that reading through another local doctor. My most recent experience about considering gender was when I had a carotid intimal thickness ultrasound here in Canada. The results said I had the carotid arteries “of a 69-year-old” and I’m 64. I asked if that was a man or woman I was being compared to and if there is a difference in the interpretation. No one had ever asked the doctor at the Lipid Clinic or the cardiologist she consulted. I will not get an answer, I’m sure. Much needs to change.

    Liked by 2 people

    • Carolyn Thomas February 4, 2018 at 10:34 am #

      Ellen, what a brilliant question to ask that doc at the Lipid Clinic after your ultrasound!! You’re so right – much needs to change!

      You are the second person to tell me of the impressive cardiac care received in a Thai hospital. The fact that your current cardiologist didn’t even want to see that angio speaks more of the arrogance of North American physicians than of the quality of foreign medical practice.

      Like

  4. Sandra Sizer February 4, 2018 at 8:48 am #

    One place to start would be at the medical school level. Train all medical students, both male and female, on the urgent need to get past gender bias and treat women’s heart symptoms seriously. Require all physicians to take yearly courses in women’s heart issues and yearly refresher courses in sensitivity training.

    None of this will solve the problem fast, but it could be a start. Offer more women’s heart health educational meetings at local hospitals. Advertise these meetings in local media. Further, crank up the AHA’s publicity campaigns. Get somebody [preferably a highly knowledgeable woman] who’s a real PR pro at the head of a really strong campaign to educate women and men and cardiologists and PCPs and other human beings on women’s heart health and/or lack thereof.

    I have yet to see these issues focused on as strongly as, for instance, the breast cancer efforts.

    And: Your blog, Carolyn, is still one of the very, very few of its kind. Neither my PCP nor my cardiologist was aware of its existence until I told them about it — and I only found it by accident.

    Liked by 1 person

    • Carolyn Thomas February 4, 2018 at 10:29 am #

      Thank you so much for your kind words, Sandra! I agree 100% with you about the crucial importance of making big changes starting in med school. Tomorrow!

      And I think this 2018 Heart Report from the Heart and Stroke Foundation is an example of a tremendous aware-building tool for all of us. Please read the whole report, and then share it with the women you care about!

      I suspect that women’s heart disease as a ’cause’ is unlikely to catch up with the pinkification called breast cancer awareness any time soon – but if we each do our little bit, I believe we can make things better for women’s hearts, one woman at a time…

      Another unexpected PR tool recently was the Grey’s Anatomy TV show all about women’s heart attacks! Strong messages about women’s atypical cardiac symptoms, cardiac risk factors, etc went blazing out over one hour to 9 million G.A. viewers. One cardiologist, Dr. Melissa Walton-Shirley reviewed the show here!

      Like

  5. Wendy Hanawalt February 4, 2018 at 8:22 am #

    This describes my mother’s experience perfectly. She was sent home with a diagnosis of indigestion, despite a medical history of heart issues. She passed a stress test with flying colors, two weeks before she died of a heart attack.

    My solution? A woman cardiologist. My cardiologist is very collaborative in her approach and takes my concerns very seriously. I recently “passed a stress test with flying colors” but she said that it was in no way a perfect test. We decided that the next appropriate step was something more conclusive. I hate to be sexist, and I’m sure there are a lot of aware male doctors, but honestly? I just find that women listen better and take me more seriously.

    Liked by 1 person

    • Carolyn Thomas February 4, 2018 at 10:20 am #

      Hi Wendy – Tragic story about your mother. My condolences to you on such a sad and preventable loss.

      I’ve met lots of male cardiologists who are awesome communicators (including my own!) But a recent study suggests that female physicians actually do have better patient outcomes compared to their male colleagues!

      This 2018 Heart Report specifically talks about the reliability of the treadmill stress test in women (=not great!) I wrote more about the treadmill test here.

      Like

  6. Michelle Marissa February 4, 2018 at 7:14 am #

    My symptoms started mid-1980’s, I had two heart attacks between late 1980 and 1990. None were recognized or believed. Anti-depressants were pushed at me, drs said it was stress, nerves, my difficult home life. All EKG’s showed nothing.

    It became humiliating to mention my continuing heart symptoms, so … I stopped mentioning them. Until days after my 69th birthday. Three very severe heart attacks within a week and a half. I told no one, chewed handfuls of aspirins until the symptoms subsided, and went about my day to day life. Until the third one, I knew I needed to tell. Called drs office, nurse said “go to ER” … I did, but three days later, I had things to arrange at home, just in case.

    I went to the ER, spent 8 hours there until an ICU bed was available. Bottom line: I had TEN blocked arteries. Betting they didn’t happen overnight, betting I was suffering all those years as each artery took its time getting blocked.

    Two male cousins had their heart disease noted after their very first symptom – both had bypass surgery … one of them only had one blocked artery, the other had two. I, the female who was ignored all those years and Rx’d anti-depressants, had TEN blocked arteries. I had quadruple bypass, only four were able to be repaired, the other six, still in me, were too small to repair.

    I’ll be 78 in two months, I survived the heart surgery – and the three day coma induced because my heart kept failing immediately after the surgery was completed. The medical team worked very hard to save my life. I’m grateful.

    But I’m not grateful to any of the drs who ignored my symptoms since my mid-40’s. Especially that heart disease was rampant in my family!

    Liked by 3 people

    • Carolyn Thomas February 4, 2018 at 10:44 am #

      Michelle, I hardly know where to start responding! TEN BLOCKAGES? I wonder how many other women have simply stopped mentioning ongoing symptoms to their physicians because they’d given up hoping to be taken seriously… And to have the concurrent examples of the speedy service offered to your (male) cousins makes this feel even worse!

      I wanted to mention family history here, since you brought it up. We know that only first-degree relatives count when it comes to determining if a person has a family history of heart disease: for example, if your Dad or brother had a cardiac event before age 55, or if your Mum or sister had a cardiac event before age 65, then you’re considered to have a family history risk factor. There’s no evidence to show any direct family history risk associated with grandparents, cousins, aunts, uncles, etc. More on that here

      Like

  7. Anne February 4, 2018 at 7:09 am #

    I think that most doctors have never experienced the conditions that they are attempting to diagnose. I think those conditions have non-known/predicted outlying symptoms and those symptoms are not taught in school – this wisdom is taught by practice. I think most medical school programs have a set agenda that includes an impossibly hard schedule and so much of it is focused on the biology/chemistry of the condition rather than the communication aspect.

    That leaves the ill patient holding the responsibility bag to communicate (one way) to their attending physician. A lot of those physicians are in a nutcracker between hospital leadership exerting financially-driven constrains (GOMER = “get out of my ER!”), financial constraints associated with the debt load carried by the physicians, exhaustion, and they have never been “just a normal mortal”. EVERY single element of their education was hand fed to them.

    My aunt fell and called the transit to take her to the hospital to be checked out. Her hip hurt. Wanna bet that she told the nurse that she fell and hurt her hip? That is what her daughter told me before telling me how she spent the day in the emergency dept with her elderly mom.

    When I called my aunt, after the fact, I asked her to describe her morning. The first response is that it was a normal morning but that she wasn’t feeling well and had gone to the kitchen to take some pain medicine, then fell and her hip hurt. She took quite a while to get well enough to get to the phone.

    “What does your normal morning look like?” Did she eat breakfast? She guessed so. “What did you eat for breakfast?”

    “Oh I have oatmeal every day then I watch TV. I got up to take some Tylenol because I didn’t feel well. While at the kitchen sink, I felt so hot – like I was in an oven then don’t recall how I got onto the floor.”

    The point of this long winded response is that to communicate with an ill person takes time and patience. Well, doctors have patients not patience in their over-scheduled day.

    My aunt was sent home with a bottle of baby aspirin and told to return if she felt chest pains. Hmmm. So many heart attacks have no chest pains. GOMER. She got turfed from the ER because she didn’t meet the hospital “metrics” on what a heart attack should look like.

    I told her to call her GP and request a follow up appointment within days and ask to see a cardiologist. The GP said that it could wait two weeks.

    Then the GP received the medical records from the ER visit and called her into the office the next day and my aunt was given some labs and a Holter monitor to begin to obtain the data to truly diagnose – to rule in/out – whether the heart was involved.

    The point being is that wisdom comes with experience. Knowledge comes from education…but it’s wisdom and the ability to communicate that moves the rock.

    Liked by 2 people

    • Carolyn Thomas February 4, 2018 at 10:14 am #

      Beautifully said, Anne. And another reminder that sometimes the presenting complaint is NOT the MOST IMPORTANT problem, particularly with the elderly like your aunt, who often have lots of other health problems, or with those who live with mental health issues. And yes, it is possible to have both a sore hip and heart disease, or anxiety and a heart attack… all at the same time.

      I really don’t expect my physicians to have to go through a cardiac event in order to diagnose/treat me appropriately (my GP who sent me straight to hospital for a ruptured appendix at age 16, for example, had never suffered appendicitis himself, but what he did have was curiosity, knowledge, and then a willingness to make swift medical decisions about my care based on current treatment guidelines).

      Although I do agree with you – I’m sure that when doctors do become patients, they can’t help but become better doctors.

      Like

  8. Gary Binkley February 4, 2018 at 6:36 am #

    About 20 years ago, my Dad went to emergency because he felt very bad, and knew something bad was going on. (He was 81). He could barely talk, couldn’t walk, and couldn’t think normally. We sat with him in a small room for about 2 hrs, then a young doctor came in and told us “we should take him home, he just a lonely old man seeking attention”. We called Dad’s personal doctor and he immediately called the emergency room, and insisted they admit him, until he (the personal doctor) could get there and examined him.

    Another hour later they took him upstairs for treatment. Dad was having a STROKE!

    Dad recovered slowly, lots of therapy, and lived another 5 years, before the internal damage from the slow action on the stroke, caught up with him.

    Liked by 1 person

    • Carolyn Thomas February 4, 2018 at 10:03 am #

      Gary, that’s a horrible story: “…he’s just a lonely old man seeking attention”. Appalling! You bring up such an important point: it’s not only women heart patients who are dismissed – the elderly face barriers to appropriate care for many conditions that most of us can’t even imagine. Thank goodness you called your father’s GP.

      Do you wonder what happened to that young doctor who misdiagnosed your Dad? My guess: absolutely nothing, given that our healthcare systems do not require mandatory reporting of diagnostic errors.

      Like

  9. Holly Shaltz February 4, 2018 at 5:30 am #

    I think the only change that would actually work would be requiring all cardiologists to be women who have survived heart attacks!

    And less than a month ago a (male) Mayo Clinic cardiologist told me my 2x month chest pain, not associated with exertion, starting in the cheekbone and then centered in my heart, was acid reflux. I’ve had acid reflux, and assured him this was nothing like it, but was dismissed anyway.

    Liked by 2 people

    • Carolyn Thomas February 4, 2018 at 6:06 am #

      Thanks for this, Holly. Somehow, I suspect that your recommended change ain’t gonna happen any time soon (although there’s nothing quite like doctors who become patients to finally ‘get’ it, as I wrote about here). Also I know it’s possible to be a male cardiologist (or an Emergency physician) without a cardiac history, yet still able to take women’s symptoms seriously – because I have met lots of them!

      Now, I’m not a physician, but I can tell you quite confidently that pain at rest in the cheekbone is quite likely NOT acid reflux. It may well not be heart-related (you just don’t know yet) but acid reflux? What a totally non-creative, out-of-the-blue guess!! That should be downright embarrassing to the entire medical profession!

      Almost as bad as when I witnessed my friend being told by a hospitalist (trailing a small gaggle of med students behind him!) that her Stevens-Johnson Syndrome (that had swollen her eyes, throat, tongue, lips into massive bloody weeping sores) was “Bell’s Palsy”….

      Yikes.

      Liked by 1 person

    • Charlotte Burnham February 4, 2018 at 10:51 am #

      Holly, I think you best describe our experience when you say you were “dismissed anyway”.

      I am finding that my doctors are more and more likely to dismiss my symptoms as I have hit middle age, gained weight, and developed a serious of symptoms that don’t “fit in the box”.

      Most recently has been a long series of misdiagnoses related to what is now finally being recognized as a rare autoimmune disease that nearly resulted in blindness several weeks ago. I had been persistently complaining of the painful symptoms for months, but was continued to be treated for anxiety, depression and a nod to fibromyalgia (always with a reference to how pain & depression go hand in hand).

      Now, the treatment for this disease involves high dose steroids which is causing heart symptoms….I am trying to get the new doctor’s attention about that…and you guessed it–being dismissed. It’s a lot of work to be a patient (I know you’ve written a bit about this, Carolyn!), and this week will be all about getting attention for this too.

      Another thing that has had me relating to this experience of women being dismissed was watching this week’s Grey’s Anatomy. For those who haven’t seen it, it’s an episode where a woman doctor checks herself into another hospital’s ER with a self-diagnosed heart attack. Yet, in spite of her knowledge, experience and otherwise respect in her field, she is questioned and dismissed as a possible heart attack patient after the most basic screenings.

      Most significant to her screening was that once they identified her as being under chronic stress (who isn’t?) and taking anxiety meds, she was told that her heart is fine. Ultimately, of course, in the world of TV land, her colleagues swoop in and correctly diagnose her and save her life.

      How lucky for her–but what about the rest of us who can’t get past the doctors who have us profiled as anxious, stressed, depressed and with gastric reflux? There doesn’t seem to be a way to get their attention focused on our real symptoms until we are in critical condition.

      Liked by 3 people

      • Carolyn Thomas February 4, 2018 at 11:12 am #

        Charlotte, I’m so glad you weighed in here with your compelling story, picking up on Holly’s discouraging “dismissed anyway” comment. Sheeesh…. when does it end? Why is it necessary to FIGHT to be taken seriously? Good luck to you this week…

        I too watched the Grey’s Anatomy episode this past week (just in time to kick off HEART MONTH!) Here’s a very good review of that show by cardiologist Dr. Melissa Walton-Shirley. I agreed with her take, and I’ll also add that the scene where the Chief of Cardiology meekly steps aside to allow the (superior) cardiologist from another hospital step in to save the day was a bit much!!!

        Like

  10. Francene Miller February 4, 2018 at 5:19 am #

    I think your assessment is spot on and it is shameful to realize that in this day and age, women are still being treated as second class citizens.

    I appreciate your website and I appreciate that due to your experience you have provided the rest of us with information that assures us that we have the very best information available to us.

    There is one other issue that seems prevalent in this situation and that is the issue of woman not wanting to make a fuss or, as I call it: “Everyone in the family is more important than me.”

    Sorry ladies, that simply is not true.

    Liked by 2 people

    • Carolyn Thomas February 4, 2018 at 6:14 am #

      You have hit upon such an important point, Francene! Our need to put everybody else’s needs ahead of our own, and our reluctance to make a fuss is actually well-documented. There are in fact countless clinical researchers whose specialty is studying what they call women’s “treatment-seeking delay” during a heart attack!

      This has got to stop! I’m hoping that with my daughter’s generation (she’s in her 30s) we might start seeing an end to this pervasive tendency among women.

      Like

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