{"id":37104,"date":"2026-06-26T05:41:32","date_gmt":"2026-06-26T00:11:32","guid":{"rendered":"https:\/\/atsixty.com\/?p=37104"},"modified":"2026-06-26T05:42:27","modified_gmt":"2026-06-26T00:12:27","slug":"menstrual-physiology","status":"publish","type":"post","link":"https:\/\/atsixty.com\/index.php\/obg\/menstrual-physiology\/","title":{"rendered":"Menstrual Physiology"},"content":{"rendered":"\n\n\n<meta charset=\"UTF-8\">\n<meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0\">\n<title>Morning Rounds \u00b7 Menstrual Physiology, Examination &amp; Informed Consent<\/title>\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:ital,wght@0,400;0,600;0,700;1,400;1,600&#038;family=Source+Serif+4:ital,wght@0,300;0,400;0,600;1,400&#038;display=swap\" rel=\"stylesheet\">\n<style>\n#gyn01 *,#gyn01 *::before,#gyn01 *::after{box-sizing:border-box;margin:0;padding:0}\n#gyn01{\n  --ob:#4B3A6E;\n  --ob-light:#5F4D85;\n  --ob-pale:#EFE9F5;\n  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.mr-band-s{background:var(--ob-pale);color:var(--ob)}\n#gyn01 .mr-retry{display:block;margin:18px auto 4px;background:transparent;border:2px solid var(--ob);color:var(--ob);border-radius:8px;padding:9px 28px;font-family:'Playfair Display',serif;font-size:0.92rem;font-weight:700;cursor:pointer}\n#gyn01 .mr-retry:hover{background:var(--ob);color:#F3EFFA}\n@media(max-width:480px){#gyn01 .mr-title{font-size:1.4rem}#gyn01 .mr-num{font-size:1.7rem}#gyn01 .mr-stem{font-size:0.9rem}#gyn01 .mr-opt-text{font-size:0.86rem}}\n<\/style>\n\n<!-- SVG Q5: Screening vs Diagnostic in cervical pathology -->\n<div id=\"gyn01-img1\" style=\"display:none\">\n  <figure class=\"mr-img-wrap\">\n    <svg viewBox=\"0 0 560 175\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" style=\"width:100%;max-width:560px;display:block;margin:0 auto\">\n      <rect x=\"0\" y=\"0\" width=\"560\" height=\"175\" rx=\"8\" fill=\"#f2eef8\"\/>\n      <text x=\"14\" y=\"18\" fill=\"#241B36\" font-size=\"9.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Screening vs Diagnostic Testing in Cervical Pathology<\/text>\n      <rect x=\"10\" y=\"26\" width=\"265\" height=\"22\" rx=\"3\" fill=\"#4B3A6E\"\/>\n      <text x=\"142\" y=\"41\" text-anchor=\"middle\" fill=\"#F3EFFA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Screening (Pap smear, HPV co-test)<\/text>\n      <rect x=\"285\" y=\"26\" width=\"265\" height=\"22\" rx=\"3\" fill=\"#4B3A6E\"\/>\n      <text x=\"417\" y=\"41\" text-anchor=\"middle\" fill=\"#F3EFFA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Diagnostic (Colposcopy + biopsy)<\/text>\n      <rect x=\"10\" y=\"50\" width=\"265\" height=\"26\" rx=\"2\" fill=\"#fdf6e4\"\/>\n      <text x=\"142\" y=\"67\" text-anchor=\"middle\" fill=\"#8a6d1a\" font-size=\"7.3\" font-family=\"Georgia,serif\">Gives a risk category, not a yes\/no answer<\/text>\n      <rect x=\"285\" y=\"50\" width=\"265\" height=\"26\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"417\" y=\"67\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.3\" font-family=\"Georgia,serif\">Gives histological confirmation, a yes\/no answer<\/text>\n      <rect x=\"10\" y=\"78\" width=\"265\" height=\"26\" rx=\"2\" fill=\"#fdf6e4\"\/>\n      <text x=\"142\" y=\"95\" text-anchor=\"middle\" fill=\"#8a6d1a\" font-size=\"7.3\" font-family=\"Georgia,serif\">No procedural risk beyond the smear itself<\/text>\n      <rect x=\"285\" y=\"78\" width=\"265\" height=\"26\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"417\" y=\"95\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.3\" font-family=\"Georgia,serif\">Carries minor procedure-related risks<\/text>\n      <rect x=\"10\" y=\"106\" width=\"265\" height=\"26\" rx=\"2\" fill=\"#fdf6e4\"\/>\n      <text x=\"142\" y=\"123\" text-anchor=\"middle\" fill=\"#8a6d1a\" font-size=\"7.3\" font-family=\"Georgia,serif\">An abnormal result raises probability, not proof<\/text>\n      <rect x=\"285\" y=\"106\" width=\"265\" height=\"26\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"417\" y=\"123\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.3\" font-family=\"Georgia,serif\">Result is the basis for treatment decisions<\/text>\n      <text x=\"14\" y=\"150\" fill=\"#4A3D63\" font-size=\"7.3\" font-family=\"Georgia,serif\" font-style=\"italic\">An abnormal screening result &mdash; however specific the combination sounds &mdash; does not substitute for histological confirmation before treatment.<\/text>\n    <\/svg>\n  <\/figure>\n<\/div>\n\n<div id=\"gyn01\">\n\n  <div class=\"mr-header\">\n    <div class=\"mr-eyebrow\">Morning Rounds &middot; Gynaecology Series &middot; Round 01<\/div>\n    <div class=\"mr-title\">\n      Menstrual Physiology, Examination &amp;<br><em>Informed Consent<\/em>\n    <\/div>\n    <div class=\"mr-subtitle\">Five cases &middot; Normal physiology, baseline assessment &amp; procedural consent &middot; Trust your instinct<\/div>\n    <div class=\"mr-chips\">\n      <span class=\"mr-chip\">5 Cases<\/span>\n      <span class=\"mr-chip\">+4 \/ &minus;1 scoring<\/span>\n      <span class=\"mr-chip\">Options reshuffled<\/span>\n    <\/div>\n  <\/div>\n\n  <div class=\"mr-sentinel\" id=\"gyn01-sentinel\"><\/div>\n\n  <div class=\"mr-progress\" id=\"gyn01-progress\">\n    <div class=\"mr-prog-inner\">\n      <div class=\"mr-pips\" id=\"gyn01-pips\"><\/div>\n    <\/div>\n  <\/div>\n\n  <div class=\"mr-body\">\n    <div id=\"gyn01-cases\"><\/div>\n    <div class=\"mr-submit-wrap\">\n      <button class=\"mr-btn\" id=\"gyn01-submit\">Submit for Debrief<\/button>\n    <\/div>\n    <div class=\"mr-score\" id=\"gyn01-score\">\n      <div class=\"mr-score-in\">\n        <div class=\"mr-score-ey\">Round Complete<\/div>\n        <div class=\"mr-ring\" id=\"gyn01-ring\">\n          <div class=\"mr-ring-in\">\n            <span class=\"mr-ring-pct\" id=\"gyn01-pct\">0%<\/span>\n            <span class=\"mr-ring-sub\">net<\/span>\n          <\/div>\n        <\/div>\n        <div class=\"mr-score-title\">Your Debrief<\/div>\n        <div class=\"mr-score-net\" id=\"gyn01-net\"><\/div>\n        <div class=\"mr-verdict\" id=\"gyn01-verdict\"><\/div>\n        <div class=\"mr-bands\">\n          <span class=\"mr-band mr-band-c\" id=\"gyn01-ct-c\"><\/span>\n          <span class=\"mr-band mr-band-w\" id=\"gyn01-ct-w\"><\/span>\n          <span class=\"mr-band mr-band-s\" id=\"gyn01-ct-s\"><\/span>\n        <\/div>\n        <button class=\"mr-retry\" id=\"gyn01-retry\">&#8635; New Round<\/button>\n      <\/div>\n    <\/div>\n  <\/div>\n\n<\/div><!-- end #gyn01 -->\n\n<script>\n(function () {\n  'use strict';\n\n  var NS    = 'gyn01';\n  var TOTAL = 5;\n  var MAX   = 20;\n  var LTRS  = ['A','B','C','D'];\n\n  var QS = [\n\n    {\n      id:      1,\n      tag:     'Normal Menstrual Physiology &mdash; History-Taking',\n      stem:    'A 24-year-old reports menstrual cycles every <strong>26&ndash;32 days<\/strong>, lasting <strong>4&ndash;7 days<\/strong>, with flow she describes as moderate &mdash; about 3&ndash;4 pads a day, no flooding, no clots larger than a coin &mdash; and no bleeding between periods. How should this menstrual history be classified?',\n      correct: 'This is a normal menstrual pattern by FIGO criteria &mdash; cycle frequency 24 to 38 days, flow duration up to 8 days, no intermenstrual or postcoital bleeding, and no flooding or large clots; no further evaluation is needed beyond this history, and reassurance is the appropriate response',\n      opts: [\n        'This is a normal menstrual pattern by FIGO criteria &mdash; cycle frequency 24 to 38 days, flow duration up to 8 days, no intermenstrual or postcoital bleeding, and no flooding or large clots; no further evaluation is needed beyond this history, and reassurance is the appropriate response',\n        'A cycle length that does not consistently land on exactly 28 days indicates an irregular cycle requiring hormonal evaluation, since true menstrual regularity should match the textbook 28-day figure rather than the broader range now accepted as normal',\n        'Using 3 to 4 pads a day this consistently should be quantified with a menstrual pictogram or treated as excessive until proven otherwise, since any reported pad count beyond two per day is generally considered a marker of heavy menstrual bleeding',\n        'Though reassuring on history, a normal cycle cannot be confirmed without a baseline pelvic ultrasound to exclude structural causes of bleeding, since history alone is an insufficient basis for classifying menstrual bleeding as normal in clinical practice'\n      ],\n      exp:     'The actual yardstick for normal menstruation is the <strong>FIGO classification<\/strong> &mdash; frequency 24 to 38 days, duration up to 8 days, no intermenstrual or postcoital bleeding, and no flooding or passage of large clots &mdash; not the 28-day figure people quote as a rigid population average. This history satisfies every FIGO parameter, so reassurance without further testing is correct. <br><br>A <strong>pad count<\/strong> is a subjective, non-validated proxy for blood loss; it is not, on its own, a trigger for objective quantification or workup &mdash; pictograms and objective measurement are reserved for cases where the history itself raises concern, not applied reflexively to every count above an arbitrary number. <br><br>A <strong>reassuring history with a normal examination<\/strong> needs no imaging to be accepted as normal &mdash; pelvic ultrasound is for red flags (intermenstrual bleeding, pelvic pain, abnormal exam findings), not a routine confirmatory step for histories that already meet normal criteria.',\n      imgId:   null\n    },\n\n    {\n      id:      2,\n      tag:     'Normal Gynaecological Physiology',\n      stem:    'A 19-year-old presents anxious about vaginal discharge. She describes a clear-to-white, non-malodorous discharge that increases around mid-cycle and just before her period, with no itching, odour, or irritation. She also mentions a brief one-sided lower abdominal twinge around the same mid-cycle time, lasting a few hours. How should these findings be interpreted?',\n      correct: 'Both findings fit normal physiology &mdash; cyclical, odourless discharge reflects oestrogen-driven cervical mucus changes around ovulation and premenstrually, and the brief one-sided twinge is mittelschmerz from follicular rupture; neither needs treatment or investigation absent odour, itching, abnormal colour, or pain lasting beyond a few hours',\n      opts: [\n        'Both findings fit normal physiology &mdash; cyclical, odourless discharge reflects oestrogen-driven cervical mucus changes around ovulation and premenstrually, and the brief one-sided twinge is mittelschmerz from follicular rupture; neither needs treatment or investigation absent odour, itching, abnormal colour, or pain lasting beyond a few hours',\n        'Any volume of discharge that the patient herself notices as increased should be treated as suggestive of an underlying infection and warrants empirical antifungal or antibacterial treatment even without itching, odour, or abnormal colour, since patient-perceived increase in discharge is itself a reliable indicator of pathology',\n        'The one-sided lower abdominal twinge recurring with each cycle should be evaluated with pelvic ultrasound to exclude an ovarian cyst or early ectopic process, since cyclical one-sided pain in a reproductive-age woman should not be attributed to a benign ovulatory cause without imaging first',\n        'At 19, any reported gynaecological symptom &mdash; including cyclical discharge and minor pelvic twinges &mdash; should prompt a baseline pelvic ultrasound and STI screening regardless of specific features, since adolescent patients generally warrant a lower threshold for full gynaecological investigation than older women'\n      ],\n      exp:     'Cyclical, odourless, non-irritating <strong>physiologic leucorrhoea<\/strong> reflects oestrogen-driven changes in cervical mucus around ovulation and premenstrually &mdash; it needs no treatment in the absence of odour, itching, abnormal colour, or discomfort. A brief, self-limited, one-sided twinge around mid-cycle is classic <strong>mittelschmerz<\/strong> from follicular rupture, not a presentation that requires imaging on its own. <br><br>A patient <strong>noticing<\/strong> more discharge is not, by itself, evidence of infection &mdash; the specific features (odour, itching, colour, irritation) are what distinguish physiologic from pathological discharge, not perceived volume alone. Likewise, recurring cyclical one-sided pain that resolves within hours fits a well-recognised benign mechanism and does not, on its own, mandate ultrasound to exclude a cyst or ectopic process. <br><br><strong>Age alone<\/strong> is not an indication for investigation &mdash; the specific clinical features present (or absent) drive the decision to investigate, not a lower threshold applied reflexively because a patient is young.',\n      imgId:   null\n    },\n\n    {\n      id:      3,\n      tag:     'Baseline Gynaecological History &amp; Examination',\n      stem:    'A woman presents for a first gynaecological consultation. What does a complete baseline assessment routinely include at this visit?',\n      correct: 'Menstrual history (menarche, cycle pattern, last period), obstetric and contraceptive history, relevant sexual history, screening for red flags (bleeding, pain, discharge), abdominal exam, and a per-speculum and bimanual pelvic exam with a chaperone and consent &mdash; reserved for when clinically indicated, not every visit',\n      opts: [\n        'Menstrual history (menarche, cycle pattern, last period), obstetric and contraceptive history, relevant sexual history, screening for red flags (bleeding, pain, discharge), abdominal exam, and a per-speculum and bimanual pelvic exam with a chaperone and consent &mdash; reserved for when clinically indicated, not every visit',\n        'A pelvic examination, including per-speculum and bimanual assessment, should be performed at every first gynaecological visit regardless of the presenting complaint, since a baseline pelvic exam is considered an essential routine component independent of clinical indication, much like a baseline blood pressure check',\n        'If the presenting complaint is unrelated to menstruation or sexual activity, menstrual and sexual history can reasonably be omitted from the baseline assessment, since history-taking should be restricted strictly to the specific complaint the patient raises rather than broadened beyond it',\n        'A chaperone is only necessary for pelvic examination when the patient specifically requests one, since the examining clinician\\'s own professional judgement is generally considered a sufficient safeguard without requiring an explicit offer to be made before every first-visit pelvic assessment'\n      ],\n      exp:     'A complete baseline gynaecological assessment covers <strong>menstrual, obstetric, contraceptive, and relevant sexual history<\/strong> as a matter of course &mdash; not restricted to whatever the presenting complaint happens to be &mdash; alongside screening for red-flag symptoms and a general\/abdominal examination. A <strong>pelvic examination<\/strong> (per-speculum and bimanual) is indicated when clinically relevant to the complaint, performed with consent and a chaperone &mdash; it is not an automatic component of every first visit regardless of why the patient has come in. <br><br>Restricting history-taking to <strong>only the stated complaint<\/strong> misses context (cycle pattern, prior pregnancies, contraceptive use) that routinely shapes interpretation of the presenting problem, even when that problem seems unrelated at first glance. <br><br>The standard of practice is to <strong>routinely offer a chaperone<\/strong> for intimate examination as a matter of course &mdash; not to make it conditional on the patient specifically asking, which places the burden of safeguarding on the patient rather than the clinician.',\n      imgId:   null\n    },\n\n    {\n      id:      4,\n      tag:     'Informed Consent &mdash; Invasive Gynaecological Procedure',\n      stem:    'A woman is being counselled before an <strong>endometrial biopsy<\/strong> for postmenopausal bleeding. What must the informed consent process include before proceeding?',\n      correct: 'Discussion of the procedure\\'s purpose and what it can and cannot rule out, expected discomfort and risks (bleeding, infection, rarely perforation), its voluntary nature with the right to stop at any point, the alternative of hysteroscopy if inconclusive, and that results will be discussed with her directly &mdash; documented as part of consent',\n      opts: [\n        'Discussion of the procedure\\'s purpose and what it can and cannot rule out, expected discomfort and risks (bleeding, infection, rarely perforation), its voluntary nature with the right to stop at any point, the alternative of hysteroscopy if inconclusive, and that results will be discussed with her directly &mdash; documented as part of consent',\n        'Since postmenopausal bleeding itself is a recognised indication for endometrial sampling, formal informed consent can be abbreviated to a brief verbal mention immediately before the procedure, since the clinical indication already implies the patient\\'s agreement to proceed without further discussion',\n        'The consent discussion should specifically include an assurance that a result showing endometrial hyperplasia obligates the patient to proceed immediately to hysterectomy, since continuing with a lesser intervention would not be considered an adequately informed or responsible choice',\n        'Because endometrial biopsy is generally a quick outpatient procedure, detailed disclosure of risks such as bleeding, infection, or perforation can reasonably be omitted from consent, since extensive risk discussion for a routine outpatient procedure may cause disproportionate anxiety'\n      ],\n      exp:     'Proper informed consent for <strong>endometrial biopsy<\/strong> covers the procedure\\'s purpose and its diagnostic limits, expected discomfort and specific risks (bleeding, infection, rare perforation), its entirely voluntary nature, the alternative of hysteroscopy if inconclusive, and how results will be communicated &mdash; documented clearly. <br><br>A strong clinical <strong>indication<\/strong> for the procedure does not substitute for this process &mdash; \"the indication implies agreement\" is not how informed consent works, regardless of how compelling the indication seems. <br><br>A biopsy result showing <strong>hyperplasia<\/strong> does not pre-commit the patient to hysterectomy &mdash; management depends on the type and severity of hyperplasia and may include progestin therapy or hysteroscopic resection, with the choice remaining the patient\\'s own once results and options are discussed. <br><br>The procedure being <strong>quick and outpatient<\/strong> does not exempt the clinician from disclosing material risks &mdash; informed consent requires disclosure of risks proportionate to their seriousness, not their procedural duration.',\n      imgId:   null\n    },\n\n    {\n      id:      5,\n      tag:     'Cervical Cancer Screening &mdash; Pap &amp; HPV Co-testing',\n      stem:    'A 35-year-old\\'s routine Pap smear comes back as <strong>ASCUS<\/strong> (atypical squamous cells of undetermined significance), with a positive high-risk <strong>HPV co-test<\/strong>. What does this result mean, and what is the appropriate next step?',\n      correct: 'An ASCUS Pap with a positive high-risk HPV co-test indicates a screening abnormality that raises the probability of dysplasia but is not itself a diagnosis; the appropriate next step is colposcopy with directed biopsy, since histology &mdash; not the screening result &mdash; confirms or excludes cervical intraepithelial neoplasia',\n      opts: [\n        'An ASCUS Pap with a positive high-risk HPV co-test indicates a screening abnormality that raises the probability of dysplasia but is not itself a diagnosis; the appropriate next step is colposcopy with directed biopsy, since histology &mdash; not the screening result &mdash; confirms or excludes cervical intraepithelial neoplasia',\n        'An ASCUS result with a positive high-risk HPV co-test should be treated as a confirmed diagnosis of cervical intraepithelial neoplasia, since this specific combination of cytology and HPV positivity is considered diagnostic without requiring histological confirmation by biopsy first',\n        'Since ASCUS alone is a low-grade and often transient cytological finding, the appropriate management here is simply to repeat the Pap smear at the next routine screening interval, since the HPV co-test result does not materially change the management of an ASCUS finding',\n        'Because the cytological abnormality itself is only ASCUS &mdash; a minor and frequently insignificant finding &mdash; the positive high-risk HPV result can be regarded as incidental, and reassurance without colposcopy is appropriate provided she has no symptoms'\n      ],\n      exp:     'ASCUS with a positive high-risk <strong>HPV co-test<\/strong> raises the probability of underlying dysplasia enough to warrant <strong>colposcopy with directed biopsy<\/strong> &mdash; per standard triage algorithms, ASCUS with positive hrHPV escalates to colposcopy, whereas ASCUS with a negative HPV test can return to routine screening. <br><br>Cytology plus HPV positivity is <strong>risk stratification, not diagnosis<\/strong> &mdash; treating this combination as itself confirmatory skips the histological step that actually establishes or excludes CIN. <br><br>Defaulting to a <strong>routine repeat<\/strong> ignores the HPV result entirely &mdash; the whole point of co-testing is that a positive hrHPV result changes management for an ASCUS finding rather than leaving it unchanged. <br><br>Calling the HPV result <strong>incidental<\/strong> because the cytology is \"only\" ASCUS gets the logic backwards &mdash; the HPV status is precisely what elevates this combination above a routine repeat and into the colposcopy pathway.',\n      imgId:   'gyn01-img1'\n    }\n\n  ];\n\n  var answers  = {};\n  var answered = 0;\n  var shuffled = {};\n  var done     = false;\n\n  function byId(id) { return document.getElementById(id); }\n  function gid(suffix) { return byId(NS + '-' + suffix); }\n\n  function shuffleArr(arr) {\n    var a = arr.slice(), i, j, tmp;\n    for (i = a.length - 1; i > 0; i--) {\n      j = Math.floor(Math.random() * (i + 1));\n      tmp = a[i]; a[i] = a[j]; a[j] = tmp;\n    }\n    return a;\n  }\n\n  function countVal(val) {\n    var k, n = 0;\n    for (k in answers) {\n      if (answers.hasOwnProperty(k) && answers[k] === val) n++;\n    }\n    return n;\n  }\n\n  function buildPips() {\n    var cont = gid('pips'), i, q, wLine, wPip, line, pip;\n    cont.innerHTML = '';\n    for (i = 0; i < QS.length; i++) {\n      q = QS[i];\n      if (i > 0) {\n        wLine = document.createElement('div');\n        wLine.className = 'mr-pip-wrap';\n        line = document.createElement('div');\n        line.className = 'mr-pip-line';\n        line.id = NS + '-pl' + q.id;\n        wLine.appendChild(line);\n        cont.appendChild(wLine);\n      }\n      wPip = document.createElement('div');\n      wPip.className = 'mr-pip-wrap';\n      pip = document.createElement('div');\n      pip.className = 'mr-pip';\n      pip.id = NS + '-pip' + q.id;\n      pip.textContent = String(q.id);\n      wPip.appendChild(pip);\n      cont.appendChild(wPip);\n    }\n  }\n\n  function build() {\n    var cont, i, q, opts, card, top, numDiv, meta, tag, stem,\n        rule, optsDiv, expDiv, lbl, txt, imgDiv, imgSrc, j,\n        optEl, ltrSpan, txtSpan;\n\n    cont = gid('cases');\n    cont.innerHTML = '';\n    answers = {}; answered = 0; shuffled = {}; done = false;\n    gid('score').style.display = 'none';\n    buildPips();\n\n    for (i = 0; i < QS.length; i++) {\n      q = QS[i];\n      opts = shuffleArr(q.opts);\n      shuffled[q.id] = opts;\n\n      card = document.createElement('div');\n      card.className = 'mr-case';\n\n      top = document.createElement('div');\n      top.className = 'mr-case-top';\n\n      numDiv = document.createElement('div');\n      numDiv.className = 'mr-num';\n      numDiv.textContent = q.id < 10 ? 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