Telemedicine in the Battle with 2019 Novel Coronavirus Disease (COVID-19) in Henan Province,China: A Narrative Study

Abstract

Background and Objectives:

Based on practical services of the Henan Province Telemedicine Center (HTCC), the purpose of this study is to investigate the design, construction, implementation, and application effect of a specific telemedicine system in response to the coronavirus disease 2019 (COVID-19).

Methods:

Data on COVID-19 cases from December 31, 2019, through October 17, 2022, were collected from official websites. Data and information of telemedicine services related to COVID-19 in HTCC were collected and analyzed, and relevant graphical representations were plotted.

Results:

All the 147 COVID-19 designated hospitals in the Henan Province were covered by the specific telemedicine system. The cities near to the Hubei Province in the south of Henan tended to be with more COVID-19 cases, where more COVID-19-related telemedicine services were conducted. For the telemedicine system, function modules, including real-time monitoring, command and dispatch, intractable cases transfer, remote guidance, and data sharing, were designed and realized to deal with COVID-19. Through the system, telemedicine services involved COVID-19 such as epidemic surveillance, emergency rescue, case discussion, diagnosis and treatment, remote ward-round, and distance education were performed. During the period between February 2 and March 3, 2020, 646 COVID-19 patients were served by the telemedicine system, with an improvement rate of 73.2%.

Conclusions:

Telemedicine can improve the diagnosis and treatment of COVID-19 patients, which play a helpful role in curbing the COVID-19 epidemic. Given the current global COVID-19 pandemic and the potential re-emerge of novel zoonotic pathogens in the future, the use of telemedicine would be imperative to fight against the pandemic.

Introduction

In December 2019, an outbreak of pneumonia caused by an unknown etiology was first reported in Wuhan, Hubei Province, China. A novel beta-coronavirus, namely, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), was revealed as the causative pathogen of this acute pneumonia, which was now officially known as novel coronavirus disease 2019 (COVID-19).^1
–3 As a confirmed human-to-human transmission disease, globally, the COVID-19 pandemic has already led to far more infections and fatalities than the SARS and Middle East respiratory syndrome (MERS).^4,5

Wuhan located in China's transplantation hub, and the COVID-19 outbreak overlapped with the Spring Festival travel rush before the Chinese Spring Festival that officially started on January 10, 2020, during which hundreds of thousands of people backed to their hometown from the city they worked in, inevitably carried and spread the virus across China.^6,7 As of October 17, 2022, for mainland China, 256,268 confirmed COVID-19 cases across 31 provinces or municipalities were reported, with 5,226 fatalities (Fig. 1). Henan province geographically located next to Hubei province, at the early stage of COVID-19 outbreak, there were lots of people (hometown in Henan while work in Hubei) returned from Hubei during the Spring Festival, which increasing the transmission risk of the virus and making Henan the third most severe province of COVID-19 epidemic in China. By October 17, 2022, 3,436 confirmed cases and 22 deaths had been reported across Henan. Given the urgent situation, prevent and control measures of COVID-19 from multiaspects are warranted across every stage of the epidemic to contain the respiratory disease.

Fig. 1.

The epidemiological situations of COVID-19. (A) The daily cumulative/increase of COVID-19 cases in China, Hubei, and Henan. (B) The cumulative confirmed COVID-19 cases in China, Hubei, and Henan on October 17, 2022. COVID-19, coronavirus disease 2019.

The COVID-19 pandemic is already reshaping the way health care facilities work by effectuating changes in their procedures, approaches, contents, and use of collaboration tools, such as the popularization of telemedicine. Telemedicine has been developing rapidly in recent decades, which involves the integration of clinical applications and information and communication technologies (ICTs), aiming to help health care professionals exchange valid information and deliver medical services remotely, and to increase the number of approaches for providing medical services.^8
–10

Telemedicine may play an ideal role in managing the challenges faced by health care systems in the battle with global outbreaks of infectious diseases such as COVID-19. The implementation of telemedicine services, such as teleconsultations, remote specialty diagnoses (e.g., telediagnosis of imaging results, telepathology, and tele-electrocardiograms), and distance education, can mitigate and avoid overcrowding in hospitals, reduce patients' clinical visits in person, and save travel time for both doctors and patients, while providing the assurance and health care guidance to meet the ongoing needs of patients with exposure or infection concerns.^11
–13 Such applications of telemedicine reduce the exposure of medical staff, health public, and suspected cases to viruses and ensure that health care resources are reserved for patients in dire need of them.

Given the importance of telemedicine in the time of infectious diseases epidemic, it is necessary to evaluate the development and applications of telemedicine and its effect in the battle with COVID-19. Thus, based on the practical services of the Henan Province Telemedicine Center (HTCC) in China, the purpose of this study is to investigate the design, construction, coverage, capacity, and application effect of a telemedicine system in response to COVID-19. Findings of this study may provide reference for other regions in China and even around the world, promote the further development and implementation of telemedicine in future, and shed light on the ongoing national and international actions against the COVID-19 pandemic.

Methods

DATA SOURCES OF COVID-19 EPIDEMIC

The daily number of COVID-19 cases across China from December 31, 2019, through October 17, 2022, was collected from official websites of the National Health Commission of China (NHCC), Henan Province Health Commission (HPHC), and the National Center for Disease Control and Prevention. The cumulative incidence data reported in official web pages were calculated.

DATA OF TELEMEDICINE SERVICES

As of January 29, 2020, HPHC selected and deployed 147 designated hospitals in Henan Province to collect and treat suspected or confirmed COVID-19 cases, covering county, municipal, and provincial levels (Fig. 2). HTCC undertook the design and construction of a specific telemedicine system to connect the 147 COVID-19 designated hospitals. Telemedicine services of the system for prevention, diagnosis, and treatment of COVID-19 were performed since February 2, 2020. On March 3, 2020, experts ended their services along with the control of COVID-19 epidemic in Henan. Thus, data of telemedicine services in HTCC from February 2 to March 3, 2020, were collected and analyzed.

Fig. 2.

The distribution of the 147 COVID-19 designated hospitals in Henan Province.

STATISTICAL ANALYSIS

All retrieved data were recorded into MS Excel 2016 (Microsoft, Inc., Redmond, CA) and analyzed. ArcGIS Desktop software (version 10.2.2; Esri, USA) was used to plot COVID-19 distribution maps and perform relevant graphical representations.

Results

COVID-19 EPIDEMIC

As of October 17, 2022, a total of 256,268 confirmed COVID-19 cases were reported in mainland China. In Hubei and Henan, there were 68,437 and 3,436 confirmed cases identified, respectively. The epidemic process of COVID-19 in Henan from January 21 to March 3, 2020, shows a bell-shaped curve (Fig. 1). To be consistent with the duration of telemedicine services, the distribution maps of the cumulative confirmed COVID-19 cases in China and Henan on March 3, 2020, are described in Figure 3. Henan had the third-most cumulative confirmed COVID-19 patients, only after Hubei and Guangdong (Fig. 3A). Four cities in Henan, Xinyang, Zhumadian, Nanyang, and Zhengzhou, were the most seriously affected regions that suffered from the COVID-19 epidemic (Fig. 3B).

Fig. 3.

The distributions of cumulative confirmed COVID-19 cases in China and Henan Province on March 3, 2020. (A) China in total. (B) Henan Province.

DESIGN OF THE SPECIFIC TELEMEDICINE SYSTEM

The design framework of the telemedicine system for the prevention and control of COVID-19 is shown in Figure 4. The construction of the telemedicine system was problem, demand, and policy oriented, aiming to cover all the 147 COVID-19 designated hospitals in the Henan Province. Through the system, telemedicine services such as epidemic surveillance, emergency rescue, case discussion, diagnosis and treatment of intractable cases, distance education, and remote ward-round can be performed. To support the abovementioned services, function modules including real-time monitoring, command and dispatch, intractable cases transfer, remote guidance, and data sharing were designed and realized in the system (Table 1).

Fig. 4.

The design framework of the specific telemedicine system in response to COVID-19.

Table 1.

Function Modules of the Telemedicine System for the Prevention and Control of COVID-19

FUNCTIONS	DESCRIPTION
Dynamic real-time monitoring	Through the teleconsultation system, HPHC and the Provincial Headquarters of COVID-19 Prevention and Control can trace the development of COVID-19 epidemic in real time
Command and dispatch	All the designated hospitals can receive up to date prevention and control plan of COVID-19 in Henan as soon as possible, and act in a unified manner
Intractable cases transfer	The system can realize the unified management of COVID-19 patients and the safe transfer of intractable cases in Henan, and improve the success rate of COVID-19 treatment
Remote guidance	Provincial medical experts can remotely guide the diagnosis and treatment of suspected or intractable cases in the designated hospitals to improve the treatment efficiency of COVID-19 patients
Distance education	Through the system, the exchanges of experience from the diagnosis and treatment of COVID-19 patients, sharing of relevant technologies, and popular science propaganda can be carried out
Data sharing	The system is used in conjunction with the constructed telemedicine data exchange platform to realize real-time sharing of data related to COVID-19 patients

COVID-19, coronavirus disease 2019; HPHC, Henan Province Health Commission.

CONSTRUCTION OF THE TELEMEDICINE SYSTEM

As of February 1, 2020, the first batch construction of the telemedicine system covering 130 COVID-19 designated hospitals in Henan was completed. Furthermore, there were 8 and 9 designated hospitals were connected on 16 February and 17 February, 2020, respectively (Fig. 5A). The number of designated hospitals distributed in each city is mapped in Figure 5B. Compared with other cities in Henan, eight cities, Nanyang, Xinxiang, Zhumadian, Zhengzhou, Luoyang, Zhoukou, Shangqiu, and Xinyang, had a relatively larger number of COVID-19 designated hospitals.

Fig. 5.

The construction of the telemedicine system and distribution of the COVID-19 designated hospitals in Henan. (A) The construction process of the telemedicine system. (B) The distribution of the designated hospitals.

TELEMEDICINE SERVICES IN RESPONSE TO COVID-19

The time line and progression of COVID-19-related telemedicine services in Henan, China, are shown in Figure 6. The telemedicine system in response to COVID-19 was put into use on February 2, 2020, through which the local designated health care facilities could apply COVID-19-related telemedicine services to higher level hospitals. In terms of the intractable and urgent situation of COVID-19 epidemic, after receiving the application, comprehensive telemedicine services including teleconsultations, remote specialty diagnoses, remote ward-round, and distance education were provided simultaneously by top-tier hospitals for the local designated health care facilities.

Fig. 6.

The time line and progress of telemedicine milestones in Henan Province, China, during the COVID-19 epidemic.

As of March 3, 2020, the system has performed telemedicine services for a total of 646 COVID-19 patients, among which 473 cases got better, 116 cases had no change, and 57 cases exacerbated, respectively, with an improvement rate of 73.2% (Fig. 7A). Four cities, Xinyang, Nanyang, Zhumadian, and Zhoukou, carried out the most COVID-19-related telemedicine services (Fig. 7B).

Fig. 7.

The telemedicine service for COVID-19 in Henan Province, China. (A) Daily cumulative, get better, no change, and aggravation cases of telemedicine services in relation to COVID-19. (B) The distribution of the cumulative patients who got COVID-19-related telemedicine services.

The distribution of the effectiveness of the comprehensive telemedicine services is shown in Figure 8. Specifically, successful or unsatisfactory teleconsultation cases scattered across the COVID-19 designated hospitals. The four cities conducted the most telemedicine services tend to with the largest number of teleconsultation cases that get better after the services. Besides, between February 2 and March 3, 2020, through the telemedicine system, distance education in relation to COVID-19 was performed for all the designated hospitals, involving clinical departments such as pediatrics, obstetrics, magnetic resonance, infection management, psychiatry, and infection control (Table 2).

Fig. 8.

The distribution of the effectiveness of COVID-19-related telemedicine service.

Table 2.

Clinical Departments Performed Distance Education in Relation to COVID-19

DEPARTMENTS	DISTANCE EDUCATION CONTENTS
Pediatrics	Infection management and prevention suggestions for hospitalized children in pediatrics during COVID-19 epidemic
Obstetrics	Recommendations for the management of pregnant and lying-in women with COVID-19 infection
Respiratory intensive care unit	Diagnosis, treatment, and epidemic analysis of COVID-19
Magnetic resonance	Imaging diagnosis of COVID-19
Infection management	Important links and strategies for prevention and control of COVID-19 in medical institutions
Tuberculosis diagnosis and treatment	Treatment of COVID-19
Infectious disease	Epidemiological and clinical features of COVID-19
Thyroid surgery	Medical treatment and rehabilitation guidance for patients with thyroid disease during the COVID-19 epidemic
Psychiatry	Psychological prevention and adjustment of frontline medical workers in the battle with COVID-19
Infection control	The proper selection and use of personal protective equipment for COVID-19 prevention and control
Traditional Chinese Medicine	Overview of Traditional Chinese Medicine treatment for COVID-19
Extracorporeal support treatment center	Give life a chance—ECMO
Prenatal diagnosis center	Free prenatal screening and diagnosis technical services during the COVID-19 epidemic
Infection management	How to restore normal medical services and conduct prevention and control of nosocomial infections
Outpatient and emergency	Diagnosis and treatment plan of COVID-19

ECMO, Extracorporeal Membrane Oxygenation.

Discussion

In terms of the unprecedented COVID-19 pandemic, substantial actions involving prevention, diagnosis, and treatment at the county, municipal, and provincial levels are urgently and continuously warranted. Telemedicine, through the use of modern ICTs, can play a helpful role in increasing the access of medical institutions, physicians, and patients to health care resources and medical information, especially during a major public health emergency such as the COVID-19 pandemic. In the present study, the design, construction, application, and the corresponding effect of a specific telemedicine system in response to COVID-19 were investigated, based on the practical services of the HTCC in China. To the best of our knowledge, this is the first comprehensive account of telemedicine services, from a regional perspective, in the battle with COVID-19 in China. Findings of the current study may provide a reference for further national and international actions against COVID-19.

Compared with SARS and MERS, COVID-19 appears to be less virulent and clinically milder overall in terms of the severity and case fatality rate, with the exception of the elderly and those have underlying health issues.^14,15 However, as the third pandemic caused by the coronavirus in the 21st century, the ongoing COVID-19 has already surpassed SARS and MERS in the number of both human infections and fatalities, in a far shorter time. Thus, continuous implementation of rational antitransmission measures and aggressive medical services is urgently warranted at every stage of the epidemic.¹⁶

Since the outbreak of COVID-19, China has conducted a nationwide antivirus campaign. All of the 31 provinces and municipalities in mainland China have initiated the first-level response to a major public health emergency after the shutdown of Wuhan on January 23, 2020.^17,18 As a result, the increases in the number of COVID-19 cases in most regions in China had dropped from February 12, 2020 (Fig. 1).¹⁹

Compared with other regions in China, the Henan Province faces a different and challenging situation of COVID-19 prevention and control. In terms of geographical location, Henan is adjacent to Hubei, and Xinyang and Nanyang in the south of Henan share a long border with Hubei (Fig. 3). Henan is a transportation hub, and most of the high-speed rails and highways from Wuhan to the north of China pass through Henan.

Besides, Henan is also a populous province with lots of labor export. The COVID-19 outbreak coincided with the Chinese Spring Festival, when tens of thousands of people working in Wuhan returned to their hometown in Henan for the New Year. For example, according to the Baidu Migration Data, on February 22, 2020, the day before the shutdown of Wuhan, of the top 10 cities that have a migrant population flowing out from Wuhan, Henan accounted for 4: Xinyang, Zhengzhou, Nanyang, and Zhumadian.²⁰ Accordingly, at the beginning of the outbreak, these may be the main reasons why Henan had become the third-most severe area of COVID-19 epidemic in China (Fig. 3), which inevitably increased the difficulty of COVID-19 prevention and control.

Telemedicine played an irreplaceable role in the prevention and control of COVID-19 in Henan. On January 26, 2020, relying on the HTCC, the HPHC initiated the deployment and construction of a specific telemedicine system to the 147 COVID-19 designated hospitals in Henan. The designated hospitals covered all the cities in Henan, and their distributions were approximately in accordance with the epidemic situation of COVID-19 ( Figs. 3 and 5 ).

With the help of the top-tier hospitals from the telemedicine system, the connected county-level health care facilities can efficiently diagnose and treat suspected or confirmed COVID-19 cases on time.²¹ During the epidemic, the HPHC centralized professionals from diverse medical institutions to establish an expert library, which provided remote rounds and online guidance on the diagnosis and treatment of COVID-19 patients in the local hospitals through the telemedicine system (Fig. 4).

Telemedicine can significantly improve the screening, diagnosis, treatment, and coordination of health care for COVID-19 patients, especially in low-resource areas.^11,22,23 The current dilemma of health care systems around the world is mainly with regard to their sustained ability and capacity to provide services not only to those suffering from COVID-19 but also for patients with other acute or chronic diseases, while simultaneously protecting medical staff from indiscriminate occupational exposure. Telemedicine is efficient in allowing the real-time sharing of files, annotation of medical records, and discussion of treatment options.²⁴ In this way, in addition to helping the routine management and clinical care of COVID-19 patients, health care professionals can also provide timely guidance for the diagnosis and treatment of suspected COVID-19 cases in local hospitals.^12,21

Telemedicine may decrease the visits to fever clinic or emergency department, consequently reducing the overcrowding of health care facilities as well as the exposure of both medical staff and the public to COVID-19, which is vital to avoid the transmission of the disease. Besides, through psychological interventions, such as offering emotional support and distance education, telemedicine services contribute to the dispensation of prevention and control measures, relieving social panic, and mitigating individual suspicions of severe outcomes due to COVID-19 (Table 2).^11,25,26 Therefore, it is not surprising that health care systems worldwide are now turning to telemedicine. The conversion to telemedicine may demonstrate its value as an effective approach to curb the COVID-19 epidemic.

In Henan Province, China, from February 2 to March 3, 2020, there were more than 2,000 person-time services carried out through the telemedicine system. According to the distribution of cumulative cases of telemedicine service, the cities of Henan near to Hubei suffered more SARS-CoV-2 infections than other regions, and relatively, there were more COVID-19-related telemedicine services conducted (Fig. 7).

Telemedicine services from the top-tier tertiary hospitals played a helpful role in the early diagnosis of suspected cases, precise treatment of confirmed cases, and the improvement in the cure rate of severe COVID-19 cases (Table 1). Generally, telemedicine had helped Henan gain effective staged achievements in the battle with COVID-19. On March 19, 2020, the Henan Provincial Government announced that the response level for a major public health emergency (COVID-19) was adjusted from I to II, meaning that the COVID-19 epidemic has been mitigated to a large extent.

ACHIEVEMENTS AND EXPERIENCES

There are some challenges during the deployment and implementation of the telemedicine system. For instance, the urgent time required for construction and application, inefficient data intercommunication of heterogeneous medical information, various communication standards and audio-video transmission protocols followed by diverse ICT terminal products, and unsatisfactory data transmission quality and capacity of existing networks.^13,24 These challenges can influence the application effectiveness, service quality, and coverage of telemedicine. Thus, many response measures were conducted to address the challenges, which in turn gained a number of achievements. First, to ensure the timeliness and effectiveness of the diagnosis and treatment of COVID-19, comprehensive telemedicine services including teleconsultations, specialty diagnoses, and distance education were provided simultaneously.

Second, a dedicated medical network was provided by China Mobile, to unify standards and support the transmission speed, quality, and capacity of the data generated from telemedicine services. Third, for the 147 designated hospitals, the same hardware equipment and software system were uniformly provided and installed by HTCC free of charge, which avoided the limitations of different communication standards and transmission protocols. Besides, a special work group was established through WeChat, which mainly included software and hardware engineers and medical staff. This work group can timely provide feedback and solve the problems that occurred during the application of the system, and continuously improve the quality and efficiency of the COVID-19-related telemedicine services.

Through the construction and application of the telemedicine system in response to COVID-19, some experiences are gained as the following aspects. First, specific top-down policies need to be formulated and implemented to improve the efficiency of the construction and application of the system. Second, the positive effects of telemedicine on the prevention and control of COVID-19, such as improving the capacity and efficiency of primary hospitals, curbing the spread of SARS-CoV-2 and risk of cross infection, and relieving the pressure of local health care professionals and patients, should be propagandized and popularized across the province, to promote the acceptability of telemedicine. Third, the rapid deployment and widespread application of the telemedicine system are inseparable from the advantages of the HTCC's early-stage foundations, including but not limited to the telemedicine network covering the whole province, the unified audio-videoconferencing and data exchange platform, and a wealth of application programming interfaces and computing resources.²⁴

In addition, for each of the 147 COVID-19 designated hospitals, the principle of “deploy one, debug one, launch one” was adopted during the construction of the system, which can ensure the rapid implementation of telemedicine services.

STRENGTHS AND LIMITATIONS

The present study has some noteworthy strengths. First, this is the first study, according to our knowledge, to focus on the application of telemedicine and its effect in response to COVID-19 at the provincial level in China. To date, most studies in China focused on the epidemiological and clinical characteristics of COVID-19 patients in certain provinces or throughout the whole country, and relatively few studies have been conducted to investigate the role of telemedicine in the prevention and control of COVID-19.^{1,5
–7,27,28} Second, the salient role of telemedicine in the containment of COVID-19 was investigated. COVID-19 epidemic limited the ability of health care specialists to work on site, while telemedicine was not restricted by this situation. Telemedicine enables COVID-19 cases in underserved areas to overcome geographical and temporal limitations and obtain specialty health care services similar to those they would receive in cities.

Third, the service contents and mechanism of the specific telemedicine system were introduced, which may provide reference for similar situations in other places around the world. Moreover, we discussed the deep involvement of telemedicine in the process of diagnosis and treatment of COVID-19 as well as the corresponding effectiveness in Henan Province, China. It was observed that telemedicine can relieve patients' symptoms, and promote the cure of COVID-19 in patients.

Several limitations of this study should be acknowledged. First, to prevent and control COVID-19 effectively, comprehensive response measures involved various sectors were conducted in Henan. Although the containment of COVID-19 was achieved in time, the quantitative contribution of specific measures such as telemedicine cannot be evaluated. Identifying the most effective measures to reduce SARS-CoV-2 transmission is necessary, which can further rationalize the distribution of limited medical resources. Second, although the effectiveness percentage of telemedicine services (cure rate) involving the treatment of COVID-19 was investigated and implied a plausible positive effect, clinical randomized controlled trials have not been conducted to compare the effect between telemedicine and traditional gold standards.

In this regard, based on the findings of the current study, it is hard to conclude that telemedicine is more suitable and powerful than traditional measures in response to COVID-19. Thus, the adaption and application of such a system for other health care facilities should be with caution. Further studies are needed to fill in these knowledge gaps.

Conclusions

Given the ongoing global COVID-19 pandemic and the importance of telemedicine in the time of infectious disease outbreak, we conducted a narrative investigation of the application of telemedicine and its effects in response to COVID-19 in the Henan Province, China. Findings of this study may provide helpful information for further regional, national, and even international actions against the COVID-19 pandemic. In light of the wide distribution, high prevalence, and frequent human exposure of coronaviruses, the large genetic diversity and recurrent recombination of their genomes, sporadic jump from animals to humans, and increasing human–animal interface activities, the existing already identified coronaviruses might only be the tip of the iceberg, and there are potentially more novel and severe zoonotic pathogens left to be revealed.

Novel coronaviruses are likely to re-emerge periodically in humans due to the sporadic spillover events and frequent cross-species infections. In this regard, substantial measures involving various sectors are continuously warranted. Telemedicine is mainly used to offer remote assistance to achieve more successful prevention, diagnosis, and treatment of COVID-19 patients without face-to-face interaction and the dangers inherent in the provision of routine medical services, while it did not influence the quality of traditional palliative care. Thus, we argue that the use of telemedicine will likely allow and facilitate a major reorganization of current health care delivery systems, and play a helpful role in containing and managing the new pandemic.

Footnotes

Authors' Contributions

J.G. conceptualized, designed, and initiated the study. J.G., Q.M., and D.S. drafted the initial article. D.S., Y.Y., M.R., C.F., Z.F., L.W., and M.C. were involved in the development of methodology and discussion of article structure. J.G. and J.Z. reviewed and revised the article. All authors read and approved the final article as submitted.

Disclosure Statement

All the authors declare that they have no actual or potential competing financial interests.

Funding Information

Funding was provided by the following: Soft science project of the Henan Province medical science and technology research plan (Grant No. RKX202202022). Key research and development and promotion special project of Henan Province (scientific and technological research) (Grant No. 222102310678, 222102310178); and special funds of major science and technology project in Henan Province (Grant No. 201400210400). The funders played no role in the design, development, or interpretation of the present work. The views expressed in the article are those of the authors and do not necessarily reflect the position of the funding bodies.

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