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Spinocerebellar decline (SCD) is a neurodegenerative ache that is characterised by accelerating cerebellar ataxia.1 2 The capital affection of SCD are amble ataxia, continuing instability, limb anarchy and dysarthria.3 In addition, cone-shaped tract, extrapyramidal or borderline afraid affection can action in patients with some types of SCDs.3 Ancestral SCA6, SCA31 and desultory cortical cerebellar decline (CCA) mainly appearance cerebellar symptoms, while ancestral SCA1, SCA2, SCA3 (Machado-Joseph disease) and desultory assorted arrangement decline (MSA) appearance cerebellar affection and extracerebellar symptoms. The attendance of extracerebellar affection additionally contributes to a patient’s affliction and may baffle with appraisal of the severity of cerebellar ataxia. Therefore, it is advised added advantageous to appraise the aftereffect of a biologic on cerebellar anarchy in patients with absolute cerebellar symptoms.

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Thyrotropin-releasing hormone (TRH) is a hypothalamic hormone that promotes thyroid-stimulating hormone and prolactin (PRL) absolution from the pituitary gland, and acts broadly on the axial afraid arrangement to actuate several neurotransmitters.4–7 TRH has been apparent to advance anarchy in an anarchy abrasion archetypal with a CACNA1A mutation, the adroit gene for SCA6.8 9 In a 2-week, double-blind, placebo-controlled balloon in 254 SCD patients, the ability of a TRH alternation (TRH tartrate) was accustomed in patients with predominantly ataxic forms of SCD.10 Thus, the aboriginal TRH alternation was accustomed in Japan in 1985 for the assay of anarchy associated with SCD. However, in the antecedent analytic trial, the analytic belief for SCD were not constant with contempo analytic criteria. Further, over 60% of patients with the predominantly ataxic forms of SCD had olivopontocerebellar atrophy, and the biologic furnishings were not adjourned application an anarchy appraisement calibration alone. Finally, the continuance of the balloon was alone 2 weeks. Therefore, well-designed double-blind trials were advised all-important to authenticate the ability of new biologic candidates for cerebellar ataxia.11 12

Rovatirelin is a new TRH analogue,13 which showed college affection for animal TRH receptors and greater assimilation and alteration into and adherence in the academician than the absolute TRH analogue, taltirelin.14 15 The furnishings of rovatirelin on the ataxic rolling Nagoya mice, which backpack a alteration in the CACNA1A gene, were added almighty and lasted best than those of taltirelin (data on file). To investigate the ability and assurance of rovatirelin for the assay of cerebellar ataxia, we performed two large-scale, randomised, double-blind, appearance 3 studies in patients with absolute cerebellar affection of SCD.

Two agnate multicentre, randomised, double-blind, placebo-controlled, appearance 3 studies (KPS1301 and KPS1305) were conducted in Japanese patients with SCD. Patients were enrolled from 86 hospitals in Japan amid 9 October 2013 and 30 May 2014 in KPS1301 and from 62 hospitals in Japan amid 15 November 2016 and 1 August 2017 in KPS1305.

Both studies included patients age-old ≥20 years with alone absolute cerebellar affection of SCD (CCA or genetically accepted SCA6 or SCA31). The assay of CCA was mainly based on the idiopathic cerebellar anarchy analytic belief proposed by Yoshida et al.16 Briefly, patients with boring accelerating adult-onset cerebellar anarchy and with no first-degree or second-degree ancestors with anarchy were enrolled, while patients with autoimmune-mediated, metabolic, alcoholic and drug-induced anarchy were excluded. In addition, patients with MSA were anxiously afar based on the added accord account for the assay of MSA.17 A abundant analytic breeze diagram of CCA is apparent in online added amount 1.

The KPS1301 abstraction included patients with truncal anarchy (Scale for the Appraisal and Appraisement of Anarchy (SARA)18 19 absolute account of ≥6 and SARA amble account of 2–6). The KPS1305 abstraction included patients with both truncal and limb anarchy (SARA amble account of 2–6, attitude account of ≥2 and array of ≥1 for the feel chase, nose-finger and fast alternating duke movements tests (patients with array of ≥1 on unilateral tests were included if tests were not achievable on the appropriate or larboard ancillary for some acumen added than the primary disease)).

Exclusion belief were: accessory anarchy (eg, cerebrovascular disorder, academician tumour, assorted sclerosis, hypothyroidism, drug-induced, paraneoplastic syndrome); doubtable alcoholic ataxia; motor anarchy due to musculoarticular disease; cerebral impairment, abasement or added brainy diseases and a assay of thyrotoxicosis. In the KPS1305 study, patients who had alternate in a rovatirelin abstraction ≥2 years ago were adequate to enrol; however, this accumulation of patients was belted to ≤30% of the absolute cardinal of patients enrolled in KPS1305.

Patients were randomised application an Interactive Web Response Arrangement by an absolute organisation. They accustomed rovatirelin 1.6 mg, rovatirelin 2.4 mg or placebo (1:1:1) in the KPS1301 study, and rovatirelin 2.4 mg or placebo (1:1) in the KPS1305 study. In KPS1305, the presence/absence of accord in a antecedent analytic abstraction of rovatirelin was included as a stratification agency for activating allocation. All patients and cadre complex in the study, including the board and study-site staff, were masked to the assay assignment. The assay agents were duplicate from one another, and adequation was accepted at the time of assay abettor allocation and at the end of the study. After-effects of the endocrinology tests were stored at the barometer academy until unblinding.

Both studies included a single-blind 4-week pretreatment period, during which alone the patients were addled and were accustomed articulate placebo already circadian afterwards breakfast. Thereafter, beneath double-blind conditions, adequate patients accustomed articulate rovatirelin or placebo already circadian (after breakfast) for 28 weeks (KPS1301) or 24 weeks (KPS1305). In a aftereffect aeon of 4 weeks, the patients were accustomed no assay agents and underwent alone assurance evaluation. TRH analogues, CYP3A4 inhibitors and P-glycoprotein inhibitors were banned during the pretreatment and assay periods. In addition, investigational articles added than rovatirelin were banned throughout the study.

Efficacy and assurance were evaluated during hospital visits every 4 weeks. At weeks 0 through 24, SARA (Japanese version) was acclimated to appraise the amount of ataxia. Anniversary accommodating was adjourned for SARA by the aforementioned investigator, who was a board-certified neurologist of the Japanese Society of Neurology. Because differences in SARA appraisal amid board cannot be alone in large-scale, multicentre trials, the board were accomplished application a video of the SARA appraisal acclimation to abate the airheadedness in SARA assessments. Accommodating affection of action (QoL) was self-assessed application the Japanese adaptation of the Abbreviate Form-8 (SF-8) check at weeks 0 through 24.20

The primary endpoint was change in the SARA absolute account from baseline to the time point of final evaluation. The final appraisal was authentic as the latest evaluation, excluding missing data. Accessory ability endpoints were the SARA absolute score, alone SARA array and SF-8 array at anniversary appraisal time point. Assurance endpoints included adverse contest (AEs), basic signs, anatomy weight, 12-lead ECG, analytic class tests and endocrinology tests (thyroid aesthetic hormone (TSH), chargeless triiodothyronine (FT3), chargeless thyroxine (FT4) and PRL). Board evaluated AEs for severity (mild, abstinent or severe) and for causal relationships with the assay agents.

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For the KPS1301 study, bold a aberration in the change in the SARA absolute account amid the rovatirelin accumulation and the placebo accumulation of −0.75, and a accepted SD of 2.0, a sample admeasurement of 113 about assigned patients was affected as adequate to accommodate 80% ability with a alternate 5% acceptation level. In the KPS1305 study, a sample admeasurement of 87 about assigned patients was affected as adequate to accommodate 80% ability with a alternate 5% acceptation level, bold a aberration in the change in the SARA absolute account amid the rovatirelin 2.4 mg accumulation and the placebo accumulation of −1.06 and a accepted SD of 2.48.

The abounding assay set, which was acclimated for ability analysis, afar patients who were basic or ineligible, abandoned the Good Analytic Practice (GCP), discontinued afore the alpha of the assay aeon or were bare for the primary endpoint. The assurance set, which was acclimated for assurance analysis, afar patients who abandoned the GCP, were basic or discontinued afore the alpha of the assay period.

The primary endpoint in both studies and the affiliated assay was affected as the aberration in SARA absolute account amid the final appraisal and anniversary 0 (the end of the pretreatment period). The change in SARA absolute account amid the two groups was compared application assay of covariance, with the assay accumulation as the anchored aftereffect and the SARA absolute account at anniversary 0 as the covariate in KPS1301. The presence/absence of accord in a antecedent analytic abstraction of rovatirelin was additionally included in KPS1305. In KPS1301, a bankrupt testing action was acclimated for acclimation of multiplicity, and ahead of rovatirelin 1.6 mg over placebo was absolute alone afterwards ahead of rovatirelin 2.4 mg over placebo was confirmed.

We hypothesised that patients with beneath astringent anarchy appearance a added arresting placebo effect. Therefore, a subgroup assay of the primary endpoint was performed in patients in the KPS1301 abstraction who met the KPS1305 admittance belief (SARA amble account of 2–6, attitude account of ≥2 and array of ≥1 for the feel chase, nose–finger and fast alternating duke movements tests).

A affiliated attendant assay was performed that accumulated the abstracts from the aloft subgroup of KPS1301 and from all patients in KPS1305 with the aforementioned admittance belief (SARA amble account of 2–6, attitude account of ≥2 and array of ≥1 for the feel chase, nose–finger and fast alternating duke movements tests). The patients who accustomed either rovatirelin 2.4 mg or placebo and had not alternate in a antecedent rovatirelin abstraction were included. Furthermore, in the affiliated analysis, two subgroup analyses were additionally performed in patients with a baseline SARA absolute account of ≥15 and <15, because the average baseline SARA absolute account in the affiliated accumulation was 15.

The acceptation akin for anniversary alternate statistical testing was 5%. In the allegory of ability variables amid the two groups, two-sample t-tests were acclimated for connected variables. All analyses acclimated SAS V.9.4 (SAS Institute).

In the KPS1301 study, 411 patients with truncal anarchy were enrolled; 374 of these patients were included in the assurance set and 369 in the abounding assay set (figure 1A). In the KPS1305 study, 241 patients with truncal and limb anarchy were enrolled; 203 were included in the assurance set and 202 in the abounding assay set (figure 1B). The affiliated assay included 278 patients; 140 in the rovatirelin 2.4 mg accumulation and 138 in the placebo group. In both studies, there were no above between-group differences in baseline characteristics (table 1). In KPS1301, 165 patients had SCA6, 72 patients had SCA31 and 132 patients had CCA; corresponding numbers in KPS1305 were 83 (SCA6), 57 (SCA31) and 62 (CCA) patients. The beggarly baseline SARA absolute account was 12.9 in KPS1301 and 14.9 in KPS1305. In addition, the beggarly baseline SARA absolute account was lower for patients with truncal and limb anarchy in the KPS1305 abstraction adjoin patients with truncal and limb anarchy in the KPS1301 abstraction (14.9 vs 16.8, p<0.001, two-sample t-test). The SARA absolute array during the pretreatment aeon were abiding for patients who accustomed assay in the two trials (n=577; change in SARA absolute account during the pretreatment period: 0.04±1.59, mean±SD, p=0.530, one-sample t-test).

Baseline demographics and characteristics of the abounding assay set

Flow blueprint of patients included in the (A) KPS1301 and (B) KPS1305 studies. The affidavit for cessation could overlap. AE, adverse event.

Treatment was discontinued in KPS1301 by 16.0% of patients accepting rovatirelin 1.6 mg, 19.8% of patients accepting 2.4 mg and 4.9% of patients accepting placebo (figure 1A). In KPS1305, assay was discontinued by 9.9% of patients in the rovatirelin 2.4 mg accumulation and 11.8% of patients in the placebo accumulation (figure 1B). The capital affidavit for the cessation were AEs and deepening of anarchy (figure 1).

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In KPS1301, the adapted beggarly change in SARA absolute account at the final appraisal time point (primary endpoint) was −0.74 for rovatirelin 1.6 mg, −1.23 for rovatirelin 2.4 mg and −1.16 for placebo; the aberration amid rovatirelin 2.4 mg and placebo (−0.07; 95% CI −0.64 to 0.49) was not cogent (p=0.800, amount 2A).

Adjusted beggarly and 95% CI of the change in SARA absolute account from baseline (primary endpoint) in the (A) KPS1301 and (B) KPS1305 studies. P ethics were affected application the ANCOVA method. (C) Affiliated assay of patients from KPS1301 and KPS1305 studies who met the KPS1305 admittance belief (SARA amble account of 2–6; attitude account of ≥2; feel chase, nose–finger and fast alternating duke movement array of ≥1 each). ANCOVA, assay of covariance; SARA, Calibration for the Appraisal and Appraisement of Ataxia.

In the subgroup of patients with limb and truncal anarchy (n=13690, online added table 1), the adapted beggarly change in SARA absolute account at the final appraisal time point was −0.65 for rovatirelin 1.6 mg, −1.98 for rovatirelin 2.4 mg and −0.92 for placebo. In this subgroup, the aberration amid rovatirelin 2.4 mg and placebo was cogent (−1.06; 95% CI −2.08 to –0.04; p=0.041).

Based on these results, an added balloon in patients with limb and truncal anarchy was conducted (KPS1305). In KPS1305, the adapted beggarly change in SARA absolute account showed no cogent aberration amid rovatirelin 2.4 mg and placebo (−1.46 vs −1.04; aberration −0.42; 95% CI −1.02 to 0.18; p=0.165; amount 2B).

To access a added absolute appraisal of rovatirelin assay furnishings and greater statistical ability for assessment,21 abstracts from KPS1305 and the KPS1301 subgroup were combined, because the abstraction protocols for both groups were identical except for the SARA account criteria. The baseline characteristics of the affiliated accumulation (n=278) are apparent in table 1. In this affiliated analysis, there was a cogent aberration in the adapted beggarly change in SARA absolute account amid rovatirelin 2.4 mg and placebo (−1.64 vs −1.03; aberration −0.61; 95% CI −1.16 to –0.06; p=0.029; amount 2C). In alone SARA scores, decidedly greater reductions in fast alternating duke movement array were empiric with rovatirelin 2.4 mg vs placebo (−0.34 vs −0.08; p<0.001).

To assay whether rovatirelin was able in patients with added astringent ataxia, the affiliated assay accumulation was disconnected into two groups application the average baseline SARA absolute account of 15 as the severity threshold. Patients with a baseline SARA absolute account ≥15 showed a decidedly greater adapted beggarly change in SARA absolute account with rovatirelin 2.4 mg compared with placebo (−1.75 vs −0.58; aberration −1.16; 95% CI −1.95 to –0.38; p=0.003). In patients with baseline SARA absolute account <15, the aberration in adapted beggarly change in SARA absolute account amid rovatirelin 2.4 mg and placebo was not cogent (−1.54 vs −1.48; aberration −0.06; 95% CI −0.85 to 0.73; p=0.879). In the placebo group, greater account reductions were empiric in patients with a baseline SARA absolute account <15 than in those with a baseline account ≥15, admitting array were agnate amid patients with SARA absolute account <15 and ≥15 in the rovatirelin 2.4 mg accumulation (figure 3). In patients with SARA absolute account ≥15, alone SARA array were decidedly bargain with rovatirelin 2.4 mg adjoin placebo for amble (−0.18 vs 0.13; p=0.025) and fast alternating duke movement (−0.49 vs −0.11, p=0.001).

Mean±SD change in SARA absolute account from baseline for patients in the affiliated populations with a baseline SARA account of (A) <15 or (B) ≥15. SARA, Calibration for the Appraisal and Appraisement of Ataxia.

There were no apparent changes from baseline in the SF-8 concrete bloom arbitrary account or brainy bloom arbitrary account in the QoL appraisal for any of the assay groups (table 2).

Secondary endpoints

The best accepted treatment-emergent AEs (occurring in ≥5% of patients in both studies) with rovatirelin were nasopharyngitis, nausea, weight accident and bang (table 3). Accepted AEs advised to be accompanying to rovatirelin (occurring in ≥5% of patients in any rovatirelin group) were weight loss, abhorrence and decreased appetite. The majority of AEs were advised to be balmy in severity (table 3). AEs arch to assay cessation in 7.2%, 11.9% and 2.4% of patients accepting rovatirelin 1.6 mg, rovatirelin 2.4 mg and placebo, respectively, in KPS1301 (p=0.011, Fisher’s exact test) and 7.9% and 4.9% of patients accepting rovatirelin 2.4 mg and placebo, respectively, in KPS1305 (p=0.407, Fisher’s exact test; table 3).

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Adverse contest (AEs)

In patients accepting rovatirelin, beggarly TSH, FT3, FT4 and PRL levels added from baseline to anniversary 4; however, the levels were not added added with connected administering of rovatirelin. These hormone levels exceeded the accustomed ambit at some appraisal time points, and beggarly FT4 levels exceeded the advertence amount at all appraisal time credibility (online added tables 2 and 3). Beggarly FT4 levels alternate to baseline ethics during the aftereffect period. The anatomy weight of patients decreased from baseline to final appraisal in anniversary of the rovatirelin groups in KPS1301 (–2.00 kg in the 1.6 mg group, –2.16 kg in the 2.4 mg accumulation and –0.28 kg in the placebo group; p<0.001, one-way assay of variance) and in the rovatirelin accumulation in KPS1305 (–2.31 kg in the 2.4 mg accumulation vs 0.13 kg in the placebo group; p<0.001 two-sample t-test). No clinically cogent changes or allegation were empiric in basic signs, 12-lead ECG or analytic class tests.

We begin no cogent differences in ability amid rovatirelin and placebo in two -to-be randomised controlled studies in patients with absolute cerebellar affection of SCD. However, in the affiliated assay of abstracts from the two studies, rovatirelin 2.4 mg was associated with a decidedly greater abridgement in SARA absolute account compared with placebo (−1.64 vs −1.03; p=0.029) in patients with absolute cerebellar affection of SCD. This advance was added arresting in patients with almost astringent anarchy adjoin beneath astringent anarchy (−1.75 vs −0.58; p=0.003). We accede this affiliated assay to be accurate for the afterward reasons: (1) affiliated abstracts were acquired from analogously advised studies; (2) the two studies were conducted aural a almost abbreviate aeon and (3) there was no adverse of accommodating accomplishments amid studies (online added amount 2). This affiliated assay accustomed us to access a added absolute appraisal of rovatirelin assay furnishings and greater statistical ability for assessment,21 advertence that rovatirelin may be a potentially able assay advantage for cerebellar anarchy in patients with absolute cerebellar affection of SCD.

The aftereffect of rovatirelin empiric in our two alone studies was not cogent and showed bound analytic appliance during the 24 weeks assay period. In fact, both appearance 3 studies did not appearance cogent improvements in SF-8 and QoL. However, progression of SCD is about slow. It has been appear that the anniversary changes in SARA absolute account are 0.80–1.33 for SCA6 and 0.8 for SCA31.2 22 23 Considering the acuteness of SARA and apathetic progression, bound change in SARA absolute account was accepted during the ascertainment aeon called for our study. Furthermore, it should be acclaimed that QoL assessments crave abiding ascertainment periods.

Although the accommodating admittance belief for the KPS1305 abstraction were revised based on the absolute outcomes of the KPS1301 subgroup analysis, the KPS1305 abstraction did not appearance any assay aberration amid rovatirelin and placebo. Patients in KPS1305 had lower baseline SARA absolute array than those in the KPS1301 subgroup (14.9 and 16.8, respectively, p<0.001). Therefore, we hypothesised that patients with beneath astringent anarchy appearance a added arresting placebo effect. In fact, amid patients in the placebo groups, greater SARA account reductions were empiric in patients with beneath astringent anarchy than in those with astringent anarchy (−1.48 vs −0.58, respectively). On the added hand, in patients accepting rovatirelin, a agnate abatement in SARA absolute account was empiric in both groups (−1.54 vs −1.75, respectively). These allegation advance that rovatirelin ability was not empiric in the KPS1305 abstraction due to the admittance of a abundant cardinal of patients with balmy anarchy and a arresting placebo effect.

It is able-bodied accepted that analytic trials for neurodegenerative diseases about beam a ample placebo effect. Our abstraction indicates that the placebo aftereffect should be taken into application back evaluating the ability of treatments for cerebellar ataxia. Our allegation additionally advance that the placebo aftereffect can be decreased by akin assay to patients with almost astringent anarchy back developing analytic balloon protocols for cerebellar ataxia. Although the acumen for the arresting placebo aftereffect empiric in patients with balmy anarchy is unknown, patients with baseline SARA absolute array <15 were about adolescent and had a beneath ache continuance compared with patients with baseline SARA absolute array ≥15. One accessible acumen for this could be that patients with a beneath ache continuance may accept accepted bigger advance with assay accustomed in the trial. These factors should be kept in apperception and anxiously advised in analytic trials of anarchy in the future.

In our studies, rovatirelin was associated with increases in thyroid hormone levels to abreast the high banned of the advertence ranges. Best AEs (eg, abhorrence and weight loss) were advised to be attributable to these increases in thyroid hormones. However, astringent or austere AEs were rare. Assay cessation was added common with rovatirelin assay adjoin placebo. Accepted AEs arch to assay cessation were nausea, decreased appetence and insomnia, all of which were of balmy or abstinent severity. Thus, rovatirelin was advised to accept an adequate tolerability profile. However, abiding AEs with abiding rovatirelin use charge to be monitored in approaching studies.

Drugs for neurodegenerative ache are accepted to arrest decline and advance symptoms.1 Mechanistically, as a TRH analogue, rovatirelin can advance motor action by accretion assorted neurotransmitter levels9 and accepting a neuroprotective effect.24 In fact, in a pharmacological abstraction in rats, rovatirelin added locomotor action associated with added noradrenaline concentration,14 as a aftereffect of its accelerated absorption, adherence in claret and alteration into the brain.15 Added assay is all-important to appraise whether rovatirelin can arrest the progression of SCD with abiding treatment.

Our studies alone included patients with absolute cerebellar affection of SCD. The atomic pathogenesis of cerebellar decline in absolute cerebellar affection of SCD includes aberrant addendum of CAG echo sequences in the CACNA1A gene in SCA6,25 accession of the (TGGAA)n arrangement amid in an intron in SCA3126 and alloyed mechanisms in CCA.27 The actuality that rovatirelin showed ability in these altitude indicates that this biologic exerts a benign aftereffect on cerebellar action as a whole. This suggests that rovatirelin may advance motor action in patients with extracerebellar affection of SCD.

Our studies accept several limitations. Although improvements in SARA absolute account were begin in affiliated and subgroup analyses, these analyses were column hoc in nature. The studies included alone Japanese patients, which may access the generalisability of results. Although the cardinal of repeats can access the analytic severity of SCA6 and SCA31, abstracts on the cardinal of repeats were not obtained. However, as the aftereffect of the cardinal of repeats on the dissection action is about attenuate in these diseases, this abridgement of abstracts was advised to be inconsequential.2 23 28 As abiogenetic analyses were not about appropriate for CCA diagnosis, it is accessible that patients with SCA6, SCA31 or added abiogenetic disorders were included in these studies.

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 Evaluation for PR and Event Management Agencies

Evaluation for PR and Event Management Agencies | evaluation form criteria

In two all-embracing double-blind studies in patients with absolute cerebellar affection of SCD, rovatirelin was not associated with a statistically cogent change in SARA absolute account compared with placebo; however, the affiliated assay of patients with both truncal and limb anarchy adumbrated that rovatirelin is a potentially able assay advantage adjoin cerebellar anarchy in patients with absolute cerebellar affection of SCD. This advance was added arresting in patients with almost astringent anarchy than in those with beneath astringent ataxia. Added studies are bare to appraise the abiding ability and assurance of rovatirelin, as able-bodied as patient-reported outcomes.

Statistical analyses were completed by MY, Kissei Pharmaceutical, Bunkyo-ku, Tokyo, Japan. We acknowledge Yoshiko Okamoto, inScience Communications, Springer Healthcare for accouterment beat abutment and Toni Dando and Sarah Greig, of inScience Communications, Springer Healthcare for alteration and administration the arrangement for submission. This medical autograph abetment was adjourned by Kissei Pharmaceutical.

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