The man who saved countless lives
November 1, 2022 8:24 AM   Subscribe

Dilip Mahalanabis, who came up with “the most important medical discovery of the 20th century,’’ died last month. Dr Dilip Mahalanabis was one of the main movers behind Oral Rehydration Therapy (ORT, sometimes known as ORS), which can cut deaths from dehydration, especially due to diarrhea, from 30% to around 3%. Doctors had been treating dehydration with IV rehydration for decades, but that is expensive, and requires trained staff. Starting with refugee camps in Bangladesh in 1971, Dr. Mahalanabis realised that the same mixture of boiled water, sugar and salts could be given orally. It could be done quickly and cheaply, and most importantly, it didn't need a doctor. People could learn how to make the mixture, and share the recipe with neighbours.

This substack post goes into more detail about ORT, and how it was quickly and effectively spread across the world.

But it also asks the question: why isn't this a bigger story in the west? I haven't seen it reported, or an obituary run, anywhere here in the UK, and only found out via the substack link above. A quick check of Google News seems to confirm that only Indian news outlets have covered the story. Yet his work, and that of those who came before and after him, has saved millions of lives. This is a story, and a life, that deserves to be better known.
posted by YoungStencil (56 comments total) 73 users marked this as a favorite
 
One of my parents was a health care worker and I remember, as a child, seeing them preparing this mix for people going on medical mission trips to take with them. It's so simple and so effective. Dr. Mahalanabis deserves much greater recognition.
posted by praemunire at 8:44 AM on November 1, 2022


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posted by JoeXIII007 at 8:51 AM on November 1, 2022


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posted by jquinby at 9:12 AM on November 1, 2022


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posted by Lawn Beaver at 9:14 AM on November 1, 2022


Oral rehydration salts saved my brother's life when we were kids. In my mind, this is right up there with Narcan as "simple, extremely effective, literally lifesaving."

Thank you for posting this.
posted by basalganglia at 9:20 AM on November 1, 2022 [28 favorites]


A liter of water, six teaspoons of sugar, half a teaspoon of salt, is the formula I've found, for those wondering.
posted by Baxx_24 at 9:24 AM on November 1, 2022 [17 favorites]


In our fridge we keep a bottle of rehydration solution. To 500g of water add 75g of sugar, 10g of salt, 5g of No Salt (potassium chloride), and 20g of fruit acid (citric and/or malic). Shake and refrigerate. Dilute 1:8 or so and put in a water bottle for drinking in the summer, or 1:4 when recovering from some unpleasant GI issue. "You know you need it if it tastes good. If it tastes bad, you don't need it."
posted by seanmpuckett at 9:26 AM on November 1, 2022 [54 favorites]


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posted by humbug at 9:27 AM on November 1, 2022


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More Dilip Mahalanabises please. What a hero.
posted by lalochezia at 9:29 AM on November 1, 2022 [3 favorites]


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posted by ivanthenotsoterrible at 9:30 AM on November 1, 2022


The cynical side of me thinks that this is not better-known because of Capitalism. It is a simple solution with simple ingredients thus it resists being packaged and patented and marketed and sold.

Everyone should know about this. Help spread the word!
posted by vacapinta at 9:32 AM on November 1, 2022 [16 favorites]


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posted by Halloween Jack at 9:36 AM on November 1, 2022


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posted by SunSnork at 9:41 AM on November 1, 2022


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posted by The AhForgetIt Tendency at 9:49 AM on November 1, 2022


Back in like middle school I did a weekend science camp program and remember in one of the classes they talked about him and even made up and gave us little sample cups of the stuff to try. It's been years and I had totally forgotten about that till this post.
posted by Captain_Science at 10:03 AM on November 1, 2022 [3 favorites]


The cynical side of me thinks that this is not better-known because of Capitalism. I

I think it is cynical enough to think that we generally give little attention to poor people in distant countries. We don’t hear much about malaria either.

The point isn’t that ORT works better than, or even as well as, IV fluids under ideal circumstances, it’s that it’s a highly effective therapy with little need for infrastructure and skilled deliv ery. You save far more lives with a good enough treatment. The desire to find optimal therapies in richer countries isn’t principally driven by capitalism (though capitalism is not uninvolved).

We should care more about this sort of thing and Dr Dilip Mahalanabis was a true hero.
posted by Quinbus Flestrin at 10:14 AM on November 1, 2022 [14 favorites]


It's pretty mind blowing that it took one doctor to tell everyone else that dehydrated peoples mouths still work water can still be drank through the mouth.
posted by bleep at 10:18 AM on November 1, 2022 [4 favorites]


Another reason that ORT and Dr Mahalanabis are less known in Western countries is that protein nutrition and water quality tend to be better, decreasing the number and severity of infant diarrheal illnesses. ORT is a literal lifesaver when there’s need.
posted by Emmy Noether at 10:21 AM on November 1, 2022 [4 favorites]


"You know you need it if it tastes good. If it tastes bad, you don't need it."

I remember exactly that from the one time I needed it. It tasted so good.
posted by Dip Flash at 10:22 AM on November 1, 2022 [4 favorites]


The lesson here—which is particularly central in matters of public health, but presumably applies in other fields as well—is that it’s not sufficient to evaluate potential innovations exclusively in terms of how well they solve the problem they’re addressing. It’s just as important to look at how easy it is to scale and replicate the innovation. Sometimes the best approach is to innovate by making the solution less technically advanced. The basic approach behind ORT had been understood scientifically for at least two decades before Mahalanabis went to the front lines. But as the medical historian Joshua Nalibow Ruxin observed in a fascinating study of ORT’s history, the approach was ignored because “intravenous therapy appeared more scientific; there was an apparatus, and the physician could have precise control over the intake of a patient. Oral therapy appeared primitive and less controlled.” As it turned out, that “primitive” quality was a feature not a bug. It meant that anyone could administer the therapy, not just specialists.
posted by aniola at 10:24 AM on November 1, 2022 [20 favorites]


"You know you need it if it tastes good. If it tastes bad, you don't need it."

I remember exactly that from the one time I needed it. It tasted so good.


Same! I had a really bad reaction to pesticides and was given this with some kind of orange flavor. It tasted amazing! Best thing I ever tasted, I would have sworn. I tried a little later on in the same hospital stay out of curiosity (a nurse humored me) and it was like a salt demon died in my mouth.
posted by joannemerriam at 10:44 AM on November 1, 2022 [6 favorites]




It's pretty mind blowing that it took one doctor to tell everyone else that dehydrated peoples mouths still work water can still be drank through the mouth.


That is a very uncharitable reading.

It wasn't just water; it was electrolytes and sugar in severely dehydrated, mortally ill children and it acted almost as rapidly and as well as an IV of the same material. If you just "give them water through their mouths" you won't get anywhere near the cure rate.


posted by lalochezia at 10:52 AM on November 1, 2022 [24 favorites]


I knew someone was going to get me for that. I should have said "It's mind blowing that it took one doctor to tell everyone else that the same special water they were injecting into veins could also go in the mouth." Medical group think is one hell of a drug.
posted by bleep at 11:00 AM on November 1, 2022 [1 favorite]


Forgetting that people can drink medicinal water in the mouth is right up there with being angry about having to wash their hands between births & losing the cure for scurvy.
posted by bleep at 11:04 AM on November 1, 2022 [4 favorites]


The electrolytes and sugar are important but _boiled_ water is key. The symptoms of cholera and diarrhea are the immune system's way of flushing toxic microbes from the GI tract. Re-hydrating with contaminated water is no help. Hats off to Dr M!
posted by BobTheScientist at 11:12 AM on November 1, 2022 [8 favorites]


Forgetting that people can drink medicinal water in the mouth

You're still not really getting it. The specific formulation matters, not just because it's medically right but because it's relatively easy to mix anywhere, uses cheap ingredients, and is forgiving to minor errors. Also tested that it works for sick patients: drinking water is not nearly so simple a thing when you're vomiting regularly, have sores in your mouth, can't sit upright, or are passing water through to the other end at record speed. Also testing that it works in the field and promoting it to get appropriate attention. All of these things are part of Mahalanabis's life saving work.

There's been changes in the recommended formula over time. The article linked here has Mahalanabis' description:
The oral solution that we elected to use consisted of 22 gm glucose (as commercial monohydrate), 3.5 gm sodium chloride (as table salt) and 2.5 gm sodium bicarbonate (as baking soda) per liter of water. This was the simplest formula, containing the minimum number of ingredients, previously found to be effective in severely ill patients with cholera
Very simple and with ingredients likely to be on hand.

WHO's 2006 formula shows some evolution, but the ingredients aren't quite as commonplace. It's similar to the one posted above: sugar, salt, potassium chloride, and trisodium citrate. Wikipedia has more info.
posted by Nelson at 11:30 AM on November 1, 2022 [6 favorites]


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posted by TheophileEscargot at 12:19 PM on November 1, 2022 [2 favorites]


From wikipedia link above:
The optimal fluid for preparing oral rehydration solution is clean water. However, if this is not available, the usually available water should be used. Oral rehydration solution should not be withheld simply because the available water is potentially unsafe; rehydration takes precedence.[19]

posted by aniola at 12:27 PM on November 1, 2022 [6 favorites]


How is gatoraid different?
posted by 445supermag at 12:51 PM on November 1, 2022 [1 favorite]


So are sodium citrate and potassium chloride necessary or just Good To Have?

I would like to mix up a container to keep on hand for the next time I seriously get the trots, but I don't know whether or not to buy those two ingredients.
posted by wenestvedt at 12:55 PM on November 1, 2022


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posted by allthinky at 1:04 PM on November 1, 2022


How is gatoraid different?

Gatoraid is probably not readily available in a Bangladeshi refugee camp?
posted by Naberius at 1:08 PM on November 1, 2022 [9 favorites]


I promise I understand the difference between plain water & water with stuff in it. Im criticizing the way medicine is practiced and the deadly, entrenched groupthink that cuts people off from innovations like not forcing people to inject something that's digestible.
posted by bleep at 1:20 PM on November 1, 2022 [4 favorites]


How is gatoraid different?

Gatoraid is probably not readily available in a Bangladeshi refugee camp?


This is a question that deserves a respectful answer. I don't know the answer off the top of my head, but I used the internet to look at the ingredients of both Gatoraid and Pedialyte, and they are both solutions of glucose and salt in water, with some additions. I don't know how the ratios compare to the mix-it-yourself version, but both Pedialyte and Gatoraid are more or less the same thing. Which makes Naberius's snarky-sounding answer also a very sensible one. When our babies are sick where I live in the US, somebody can run to the store for Pedialyte. If we didn't live in easy distance of multiple grocery and drug stores, or were, say, snowed in, we could make the home-made version ourselves, having both salt and sugar on hand regularly.

I've heard a lot over the years about this solution and its role in reducing diarrhea-related deaths. I didn't know about Dr. Mahalanabis, and am glad to have learned about him today. Thanks, YoungStencil.
posted by Well I never at 1:24 PM on November 1, 2022 [7 favorites]


"I don't know whether or not to buy those two ingredients."

Sodium Citrate is a great ingredient to have around, especially for making cheeses, such as cheddar, melt without breaking. Great for cheese sauces, mac and cheese, and the like.

Potassium Chloride? Probably not as culinarily useful.
posted by bz at 1:28 PM on November 1, 2022 [2 favorites]


KCl is culinarily extremely useful for folks on a low sodium diet. LoSalt is ⅔ KCl, ⅓ NaCl. Pure KCl tastes vile.

Hats off to Dr Mahalanabis!
posted by scruss at 1:49 PM on November 1, 2022 [2 favorites]


This isn't a flippant question, was Dr. Mahalanabis ever considered for the Nobel prize in medicine? This is up there with artemisinin in terms of saving lives (Dr. Tu rightly received the prize for artemisinin a few years back, thus the comparison). It sounds like he deserved it, but I wouldn't be surprised if he was never even considered for something so "simple."
posted by Hactar at 2:54 PM on November 1, 2022 [2 favorites]


More of a first world problem, but consuming large amounts of ORT can't (or is much less likely to) give you hyponatremia, aka "water intoxication".
posted by meowzilla at 5:01 PM on November 1, 2022 [2 favorites]


Yeah, my answer may have been a bit snarky, but it was also completely serious. Dr. Mahalanabis's creation is not something we in our heavily urbanized, capitalized, and globally integrated world are ever likely to need. As Well I Never notes, we are never more than a couple blocks away from a cheap bottle of flavored Pedialyte or Gatorade. The mixture is redundant and unnecessary here, unless you want to make your own nutritional supplements and medicines as a lifestyle choice or something. Where it was invented and used, it was revolutionary.
posted by Naberius at 5:47 PM on November 1, 2022


Gatorade was introduced in 1965, and Pedialyte in 1966. ORS was a thing dating back to 1953 (without anybody realizing its applicability in broader contexts). It appears that David Nalin (one of Mahalanabis's peers) first realized that ORT was effective against Cholera as early as 1967.

The real answer is that ORT's broad applicability (particularly with regards to Cholera) was discovered more or less around the same time as Pedialyte and Gatorade were introduced. This was clearly an area of active study at the time - not only were those products unavailable in Bangladesh, they were barely available anywhere.
posted by schmod at 6:43 PM on November 1, 2022 [2 favorites]


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In our fridge we keep a bottle of rehydration solution. To 500g of water add 75g of sugar, 10g of salt, 5g of No Salt (potassium chloride), and 20g of fruit acid (citric and/or malic). Shake and refrigerate. Dilute 1:8 or so and put in a water bottle for drinking in the summer, or 1:4 when recovering from some unpleasant GI issue. "

This is making me wonder about keeping a well labeled 10X concentrate ORS solution in the fridge that could be diluted. Or 5X. Not sure what the saturation point is, but I made some of this up in the past year after a truly wicked dehydrated hangover and was very grateful. (And yes, it tasted good in that context and not later.)
posted by deludingmyself at 7:01 PM on November 1, 2022 [1 favorite]


How is gatoraid different?

Gatoraid tastes good even when you aren't completely dehydrated. The oral rehydration solution I've had tasted disgusting unless you were actually dehydrated. (I've never made it from scratch, we had little packets that you could mix with water.) So even if the ingredients are similar, I suspect the proportions are quite different.
posted by Dip Flash at 7:55 PM on November 1, 2022


Hactar: one could check here. But the Physiology or Medicine listings are not fully available, and the search-by-name page seems broken at the moment. Also, the Nobel folks only allow the public to see nominations once 50 years have passed, so the public can only view nominations from 50+ years ago.
posted by brainwane at 8:00 PM on November 1, 2022 [1 favorite]


But it also asks the question: why isn't this a bigger story in the west? I haven't seen it reported, or an obituary run, anywhere here in the UK, and only found out via the substack link above

I don’t understand folks saying this isn’t appreciated in the West. Gatorade and Pedialyte are pretty successful products. Medical professionals and laymen alike seem to understand how to treat dehydration. This is basic stuff.
posted by Sunflowers Beneath the Snow at 9:40 PM on November 1, 2022


This article on the history of ORT by Joshua Nalibow Ruxin, published in 1994, which looks like it may also be linked from the Substack post (I'm getting access-limited on that page so I'm not sure if it's the same link), is seriously a good read. While Ruxin cites Mahalanabis as an absolutely essential figure in bringing the practical use of ORT to light, who rightly deserves to be honored and remembered for that work, it does seem like the Indian Express article slightly overstates things by saying he "came up with" ORT. The actual history seems to be a bit longer and more complicated.

For one thing, it's not quite accurate to suggest that the solution used in ORT is the same thing you'd give intravenously. People had tried giving solutions of only electrolytes, similar to what would be given IV, orally, decades earlier, and it didn't work. There was a hypothesis that diarrhea involved a "paralysis" or disabling of sodium pumps in the gut, preventing the gut from taking up the electrolytes and causing even more water to leave the body and enter the gut. Physiology research in the 1950s and 60s revealed that this was not true; rather, the sodium pump is coupled to glucose transport, and without glucose present the gut can't take up sodium. This is why the ORT solution needs to include glucose; in diarrhea, the gut is depleted of all its normal nutrients including glucose. However, the first researchers to work on developing ORT weren't actually aware of these then-recent discoveries, and a particularly influential doctor pursued a saline-glucose oral treatment based on the older sodium-pump hypothesis. Because he was working with the wrong model, he got the salt concentration badly wrong, and his trial ended up leading to dramatic over-hydration of his patients, leading to the deaths of five of them by congestive heart failure. His failed trial appears to have made him skeptical of further work on ORT (the article hints that he may have suffered from alcoholism exacerbated by guilt and further impairing his research decisions), and his influential position meant that multiple other researchers were dissuaded from pursuing it as aggressively as they could have. However, in the end, cholera research groups in both Dhaka (then Dacca) and Kolkata (then Calcutta) were able to show that gastric infusions worked, and ORT was a viable transitional therapy from IV/gastric infusion to normal feeding. The main barrier to trying a simple oral-only route was that no one believed that patients with severe cholera, who might be in physiological shock, or vomiting frequently, would be able to drink the large volumes of liquid needed (up to 1 liter per hour according to the article). Mahalanabis appears to have trained with the Kolkata research group prior to his experience in the refugee camps in Bangladesh in 1971, which seems to have given him the necessary background to apply ORT successfully there.

Anyway, the details of the history are really fascinating, it's absolutely worth a read! It's pretty clear that indeed, racism, capitalism, and a fetishization of technology all played a role in the slow adoption of ORT by physicians generally, and American physicians in particular.
posted by biogeo at 10:25 PM on November 1, 2022 [18 favorites]


Athena is great and all, but I'm not her. I wasn't born with an endless supply of wisdom. It took me literally biking through a 122F desert/50C desert and 'drinking water, drinking water, drinking water, supersaturated on water but it just isn't sticking' and the advice of a friendly desert gas station attendant to discover the point of Gatorade.

Before that, all I knew about Gatorade was that it makes you sweat rainbows (per tv commercials).* And then a few years after that I realized that you could get electrolytes from places other than Gatorade! At this point, I can probably name them. Calcium, potassium, magnesium, sodium? I can probably give some pretty good guesses as to which foods have 'em, too. Give me another decade, I might have a sense of what they even are besides elements that we need and tightly regulate within our bodies as best we can.

So! Electrolytes help water "stick" when you're dehydrated, and we can eat or drink 'em. There's a lot of basic stuff to know in this world. Nobody knows all of it. Props to Dr Dilip Mahalanabis for doing what he did.


*(and this commercial which I loved because any basketball worth watching was all male and we knew all the names of all the players and then some woman I've never heard of before comes along and is better than Michael Jordan.)
posted by aniola at 11:03 PM on November 1, 2022


I only have a question, just on the various recipe-sharing in the thread: am I to understand the norm is that Gatorade or Pedialyte is readily available at your pharmacies but not sachets of ORS powder? Because if that's actually stocked, why not get those rather than trying to assemble from scratch and worrying about shelf life?
posted by cendawanita at 6:26 AM on November 2, 2022 [1 favorite]


They are available, for sure, cendawanita. My local pharmacy is supposed to carry them but are out of stock. Shopping online, "oral rehydration packets" is one useful search term. "Electrolyte powder" is another. I have the ingredients to hand, though, and it's much, much cheaper to mix it up at home.
posted by seanmpuckett at 7:02 AM on November 2, 2022 [1 favorite]


(Why do I have citric acid? It's a good cleaning acid, it's also good for making flavour concentrate drops along with berry extracts and saccharine tablets, plus the use as electrolyte powder. I have KCl mostly for the electrolyte mix; a tin of No Salt is cheap enough and keeps forever.)
posted by seanmpuckett at 7:05 AM on November 2, 2022


My local pharmacy is supposed to carry them but are out of stock

Well, boo. Because it's not in liquid form and convenient, they're part of my indispensable travel kit (along with charcoal tablets, and a local type of Chinese medicinal pellets that seem to work for the runs).
posted by cendawanita at 7:21 AM on November 2, 2022 [1 favorite]


Hydrating drinks is an almost lost history, sometimes mentioned in documentaries about working conditions during dangerous public works projects, like the Brooklyn Bridge. The original lemonade was very likely a salted drink with either vinegar or lemons, sweetened with molasses or sugar. It was sometimes called Haymaker's punch or switchel. The remarkable thing about inventing Gatorade was that the Florida football coach asked his in-house medical school to supply it, presumably because players were passing out from heat exhaustion during practice. Gatorade in the 1970's tasted like cold sweat, not anything like today.
posted by Brian B. at 7:48 AM on November 2, 2022 [4 favorites]


My local pharmacy is supposed to carry them but are out of stock

For what it is worth, the packets seem to be easily available online, like at Amazon. That doesn't help if you are having intestinal issues immediately, but getting some to keep on hand shouldn't be unduly difficult.
posted by Dip Flash at 8:14 AM on November 2, 2022


I was curious about the history of oral rehydration therapy because people have had mouths and dehydration for a long time. Somebody linked to this above, it's like 39 pages long, I am hoping it will answer my question. Here's what they gave for the short answer:
Since ORT requires only sugar, salts, and water mixed in proper proportions, it might be expected that some person would have discovered it-or at least a crude equivalent-long ago. However, although some cultures and societies developed oral therapies believed to be effective, no one remedy ever gained global acceptance. Rather, most cultures developed local therapies ranging from coconut milk to emetics.
posted by aniola at 8:30 AM on November 2, 2022


People with Postural Orthostatic Tachycardia Syndrome, aka "you're going to wake up as dehydrated as you would be from a night of drinking every night for the rest of your life" need oral rehydration salts daily. I need to have an extra 3mg of sodium a day on top of the normal amount in an American diet. Gatorade has 270mg of sodium per bottle. I cannot afford 11 bottles of Gatorade a day. I can juuuust afford the commercial ORSs for people with POTS (Vitassium, LiquidIV, etc.) that make it convenient even if it costs me a hundred bucks a month (not covered by insurance, btw). I have friends with the condition who can't afford that. Being able to make it from scratch is the only way they can afford to treat an extremely debilitating condition.

Although no fucking doctors ever seem to mention the sugar part. They say "more salt and water" and ignore the sugar, I guess assuming you already get too much of that? Unfortunately people with POTS tend to have a lot of GI issues irritated by sugar so we often are avoiding sugar and then wonder why the recommended treatment isn't working. Ask me about how I learned about sugar being an essential ingredient TEN YEARS INTO TREATMENT FOR THIS DISORDER.

So yeah. Thanks Dr. Mahalanabis. Your work has been incredibly important.
posted by brook horse at 10:48 AM on November 2, 2022 [3 favorites]


At some point in the past, people were taking the "Drink before you get thirsty" advice so liberally that they were drinking plain water to death. They didn't drink Gatorade because it was considered like a soda, because it was sold next to them and many formulations taste quite sweet, so people drank straight water instead. There are now "low calorie/no sugar" Gatorade formulations for the market that may not be like ORT. There are products marketed like Nuun which taut "Optimized Electrolytes For An Active Life" which just confuse people.

The Grand Canyon Summer Hiking - Hike Smart page yells:
Don’t Force Fluids
Drink When You Are Thirsty
I don't think the idea that ORT, Gatorade, or Pocari Sweat is better than water for rehydration is that well known in the developed world, especially since manual labor is uncommon. Adding salt and/or sugar to plain water would be the opposite of what people consider healthy.
posted by meowzilla at 4:24 PM on November 2, 2022


Here's a confusing article from Harvard Health which states that "simple" diluted apple juice is better than ORT when your child is vomiting. Except when the dehydration is "severe". And that doctors recommend ORT.

When treating stomach bugs, the best solution may be the simplest one

Anyway, first-world problems where water is already clean to drink, people have immediate access to an ER, and severe dehydration is uncommon.
posted by meowzilla at 5:04 PM on November 2, 2022


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