Cerebral palsy, neurogenic bladder, and outcomes of lifetime care
Aim: To determine the prevalence of symptomatic neurogenic bladder (SNB) and social and functional variables in a large sample of people with cerebral palsy (CP). Method: The medical records of 214 individuals (96 females, 118 males) with CP between the years 1990 and 2000 were retrospectively reviewed. Individuals with frequency, urgency, or incontinence were assigned Gross Motor Function Classification System levels and underwent cystometrogram/electromyelogram studies. Neurogenic bladders were classified according to the nomenclature of the International Continence Society. Results: Fifty-two patients had hemiplegia, 42 diplegia, 117 quadriplegia, and three dyskinesia. Educational levels ranged from full special education to those with graduate degrees. Thirty-five individuals in our group aged 5 to 66 years had SNB with a prevalence of 16.4%. The median age for the entire population was 9 years 7 months and for those with SNB 12 years 4 months (range 5-57y). Over 80% of individuals who underwent investigation were found to have spastic hyper-reflexic type bladders. Ninety-one percent obtained total continence or major improvement with conservative care. SNB was documented across the lifespan, educational spectrum, and functional level. Upper urinary tract pathology was infrequent. Interpretation: SNB is a common finding in individuals with CP. In most patients it is readily diagnosed and treated with conservative interventions.
Cerebral palsy, neurogenic bladder, and outcomes of lifetime care
KEVIN P MURPHY
SUSAN A BOUTIN
KATHY R IDE
1 Gillette Children's Specialty Healthcare, Lakewalk Center; 2 Wound, Ostomy & Continence Services, St. Luke's Hospital, Duluth, MN, USA.
Correspondence to Dr Kevin P Murphy, Gillette Children's Specialty Healthcare, Suite 210, Lakewalk Center, 1420 London Road, Duluth, MN 55805, USA. E-mail: email@example.com
This article is commented on by Vargus-Adams on pages 877–878 of this issue.
Accepted for publication 30th March 2012.
Published online 13th July 2012.
SNB Symptomatic neurogenic bladder
AIM To determine the prevalence of symptomatic neurogenic bladder (SNB) and social and func-
tional variables in a large sample of people with cerebral palsy (CP).
METHOD The medical records of 214 individuals (96 females, 118 males) with CP between the
years 1990 and 2000 were retrospectively reviewed. Individuals with frequency, urgency, or
incontinence were assigned Gross Motor Function Classiﬁcation System levels and underwent
cystometrogram ⁄ electromyelogram studies. Neurogenic bladders were classiﬁed according to
the nomenclature of the International Continence Society.
RESULTS Fifty-two patients had hemiplegia, 42 diplegia, 117 quadriplegia, and three dyskinesia.
Educational levels ranged from full special education to those with graduate degrees. Thirty-ﬁve
individuals in our group aged 5 to 66 years had SNB with a prevalence of 16.4%. The median age
for the entire population was 9 years 7 months and for those with SNB 12 years 4 months (range
5–57y). Over 80% of individuals who underwent investigation were found to have spastic hyper-
reﬂexic type bladders. Ninety-one percent obtained total continence or major improvement with
conservative care. SNB was documented across the lifespan, educational spectrum, and functional
level. Upper urinary tract pathology was infrequent.
INTERPRETA TION SNB is a common ﬁnding in individuals with CP. In most patients it is readily
diagnosed and treated with conservative interventions.
Incontinence has long been identiﬁed as a problem in people
with cerebral palsy (CP).
Neurogenic bladder has been
associated with incontinence in the population with CP and is
the focus of several studies.
McNeal et al.
from the University of Iowa screened 50
patients with CP and 18 patients with one or more symptoms
indicative of a neurogenic bladder were identiﬁed. At least four
were found to have a neurogenic bladder on urological assess-
ment including cystometrograms. Signiﬁcant improvement
was identiﬁed in symptomatic patients on medication.
Decter et al.
from Boston evaluated voiding functions
including cystometrograms and electromyography ﬁndings of
the external urinary sphincter in 57 children with CP. Eighty-
six percent of the children had evidence of an upper motor-
neuron injury. Treatment protocols achieved continence in
more than 75% of the children.
Studies by Drigo et al.,
Karaman et al.,
and Bross et al.
of children with CP all f ound urodynamic features consistent
with neurogenic bladder, detrusor sphincter dyssynergia, and
upper motoneuron etiology.
As noted by Borzyskowski,
there are many factors
involved in bladder control in people with CP. These factors
include age, cognitive and communication skills, mobility, and
upper extremity function together with expectations, training,
and a compatible living environment. Incontinence in the pop-
ulation with CP is, thus, much more complicated than a static
pathology of the central nervous system and associated mea-
sured bladder function.
The purpose of this study was to determine the prevalence
of people with CP being evaluated through an outpatient
rehabilitation practice. The study also sought to report func-
tional variables associated with urinary incontinence in this
Two hundred and fourteen consecutive patients with CP were
seen in clinic between 1990 and 2000 through an outpatient
rehabilitation practice. Data were collected retrospectively
through review of the medical records including any assignment
of Gross Motor Function Classiﬁcation System, Expanded and
Revised (GMFCS - E&R) levels
A detailed medical history and physical examination were
completed for all patients. All patients had been seen by board
certiﬁed pediatric or adult neurologists (depending upon their
age) with a diagnosis of CP established in the medical record.
Selection criteria for a urological w ork-up of suspected SNB
was as listed in
Figure 1. Every patient or their primary care-
giver(s) were questioned about the presence of urinary inconti-
nence, frequency, urgency, dribbling, and chronic infections.
ª The Authors. Developmental Medicine & Child Neurology ª 2012 Mac Keith Press DOI: 10.1111/j.1469-8749.2012.04360.x 945
DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY ORIGINAL ARTICLE
Frequency was d eﬁned as voiding intervals less than 2 hours
apart. Urgency was deﬁned as the sudden, compelling need to
urinate, often leading to incontinence in the absence of environ-
mental toileting facilities. Patients with one or more of these
symptoms were considered suspect for having SNB. These
patients were then reviewed by the full rehabilitation team
including speech and occupational therapists. The highest
level of educational achievement was documented from aca-
demic reports. Those with ability to answer verbally basic yes
and no questions, or activate nonverbal, simple switch mecha-
nisms to command, underwent complex cystometrogram and
electromyogram studies. Simple switch activations included
the ability to turn on or off a light, microwave, or radio device.
These individuals were felt by the rehabilitation team to be
most likely to achieve continence with appropriate training
and intervention. Electromyography using surface electrodes
attached to the pelvic ﬂoor was performed at the time of
urodynamic assessment. The computerized urodynamic mea-
suring system involved a double-lumen six or eight French
catheter with a sodium chloride solution (0.9%) at room tem-
perature u sed for ﬁll. The ﬁlling rate was 1 0cm
per min ute
for those aged 10 years and younger and 20cm
for those over the age of 10. A rectal balloon catheter was
ﬁlled with 5 to 10cm
of physiological saline for abdominal
pressure measurements. The patients were in the supine posi-
tion throughout most of the studies unless they expressed an
interest in sitting before voiding at maximal urge. Age-related
bladder capacity was estimated as chronological age plus 2, in
ounces. Saline infusion continued into the bladder until maxi-
mal urge was identiﬁed or leak point recorded. Risk for upper
tract pathology in patients was deﬁned as the presence of
retention (post-void residual more than 25% of estimated
bladder capacity) and compliance (change in bladder volume
divided by change in intravesical pressure) <20mL per centi-
O and a detrusor leak point pressure of >40cm
water, as deﬁned by McGuire et al.
Sensation of intravesical
saline infusion was determined by the individual’s perception.
Subsequent voiding cystourethrograms and renal ultrasounds
were completed if upper urological anatomy was felt to be at
risk. All documented instances of neurogenic bladder were
classiﬁed according to the nomenclature of the International
Patients categorized with neurogenic
detrusor overactivity had intravesical voiding pressures of
>40cm of water, compliance ratios of <20 with initial void and
decreased bladder capacities at maximal ﬁll. Those patients
with neurogenic detrusor underactivity had an intravesical
voiding pressures of <40cm H
O with compliance ratios >40
at maximal ﬁll, normal, or enlarged maximal bladder capacity
and retention. Positive outcomes were deﬁned as total conti-
nence day and night or major improvements (two or fewer
episodes per day of drops in urinary pads).
Table I displays age, type of CP, and sex for the overall popu-
lation (96 females, 118 males). Ages ranged from 5 to 66 years
with a median of 9 years 7 months. Individuals with pure dys-
kinesia had unequivocal involuntary movement consistent with
chorea and ⁄ or athetosis. This population was relatively small
in number compared with the entire population associated
with perinatal hypoxia in the two under age 20 and bilirubin
encephalopathy in the individual over 30 years of age. Individ-
uals with spastic quadriplegia had some component of dysto-
nia in addition, which is not uncommon.
Thirty-ﬁve individuals were identiﬁed as having SNB, the
overall prevalence being 16.4%.
Table II displays the type of
CP by age at the initial visit, GMFCS level, and sex for
Figure 1: Participant selection criteria. SNB, symptomatic neurogenic bladder; CP, cerebral palsy; RUS, renal ultrasound; VCUG, voiding cystourethrogram.
Table I: Type of cerebral palsy (CP) by age at initial visit and sex for the total population
Age group (y)
5 6–10 11–15 16–20 21–30 30+ Total
Total (F ⁄ M) 36 (15 ⁄ 21) 75 (31 ⁄ 44) 38 (19 ⁄ 19) 19 (9 ⁄ 10) 16 (8 ⁄ 8) 30 (14 ⁄ 16) 214 (96 ⁄ 118)
Total (%) 16.8 35 17.8 8.9 7.5 14 100
Hemiplegia (F ⁄ M) 3 ⁄ 17⁄ 14 9 ⁄ 53⁄ 31⁄ 31⁄ 224⁄ 28
Diplegia (F ⁄ M) 4 ⁄ 39⁄ 11 2 ⁄ 32⁄ 10⁄ 32⁄ 222⁄ 20
Spastic quadriplegia (F ⁄ M) 8 ⁄ 17 15 ⁄ 19 8 ⁄ 10 4 ⁄ 54⁄ 510⁄ 12 49 ⁄ 68
Dyskinesia (F ⁄ M) 0 ⁄ 10⁄ 11⁄ 01⁄ 2
F, female; M, male.
What this paper adds
• Identified a prevalence of 16.4% of symptomatic neurogenic bladder in a large
sample of people with CP.
• A 90% continence rate can be achieved with nonsurgical care.
• Urinary continence is related to ability to communicate and environmental
opportunity to succeed.
946 Developmental Medicine & Child Neurology 2012, 54: 945–950
patients with SNB. The median age for the bladder subgroup
was 12 years 4 months, (range 5–53y). The highest percentage
of people presenting with SNB were between the ages of 6
and 10 years (31%). There were 75 children in the study
between the ages of 6 and 10, eleven of whom presented with
symptoms of urinary dysfunction (15%). These children had
not been continent at an earlier age and had concerns about
wetness in the school setting, camping, and particularly sleep-
overs with friends. The next highest percentage of individuals
presenting with SNB occurred after the age of 30 years (26%).
Thirty individuals in this study over the age of 30, nine of
whom presented with symptoms of urinary dysfunction
(30%). Three of these individuals had been continent earlier
in their life but had developed symptoms with incontinence
later. Two of these individuals had spastic quadriparesis,
GMFCS level V, w ith neurogenic detrusor underactivity and
neurogenic pelvic ﬂoor overactivity on urodynamic testing.
Retention was thought to be related to the development of an
overstretched bladder with outﬂow obstruction. One of these
two individuals also had signiﬁcant hydronephrosis with grade
II vesical ureteral reﬂux (ascending to the renal pelvis) and fre-
quent urinary tract infections. The third individual had spastic
quadriparesis (GMFCS level IV). She had lost ambulatory
skills and could not mobilize to and from the bathroom
quickly enough to maintain continence. The addition of a new
postural walker and ankle–foot orthosis allowed her to access
the bathroom more quickly and achieve again the continence
she had enjoyed earlier in life.
SNB in the overall population was evenly distributed
between males and females. Patients with SNB were seen at
least every 6 months with follow-up examinations. Mean
follow-up time was 6 years 7 months. Approximately 80% of
the study participants resided within a family home or under
some form of foster care. Individuals residing within a family
home were generally aged 21 or less. Most of the remaining
individuals were residing in community group homes requir-
ing some form of physical assistance. Four adults were living
independently in the community within their own home and
The presence of SNB was seen across all GMFCS levels
and distributed equitably between those having diplegia and
spastic quadriparesis (Table II). Nine of 42 with diplegia and
26 of 117 with spastic quadriparesis had SNB with a preva-
lence of 21.4% and 22.2% respectively. This stands in contrast
to individuals studied with hemiplegia in whom none were
identiﬁed as having SNB. The most common presenting
symptoms for the subgroup of individuals with urinary
dysfunction were incontinence, both nocturnal and diurnal,
followed by urgency and frequency. Constipation was not felt
to be problematical; it was usually managed with supplemental
ﬁber and augmented ﬂuid intake.
Table III identiﬁes the type of neurogenic bladder as
obtained through urodynamic studies by type of CP, GMFCS
level, and sex for the patients with SNB. Mean bladder capac-
ity at maximal ﬁll for those with neurogenic detrusor
overactivity was 51% of expected. Neurogenic detrusor under-
Table II: Cerebral palsy (CP) type by age at initial visit, functional status, and sex for individuals with urinary dysfunction
Age group (y)
5 6–10 11–15 16–20 21–30 30+ Total
Total (F ⁄ M) 4 (4 ⁄ 0) 11 (3 ⁄ 8) 7 (3 ⁄ 4) 0 4 (1 ⁄ 3) 9 (6 ⁄ 3) 35 (17 ⁄ 18)
Diplegia (F ⁄ M)
GMFCS I 0, 0 (0 ⁄ 2) (0 ⁄ 1) 0, 0 (0 ⁄ 3)
GMFCS II 0, 0 (0 ⁄ 2) 0, 0 (1 ⁄ 0) (2 ⁄ 0) (3 ⁄ 2)
GMFCS III 0, 0 (0 ⁄ 1) 0, 0 0, 0 0, 0 (0 ⁄ 1)
Spastic quadriplegia (F ⁄ M)
GMFCS II 0, 0 (0 ⁄ 1) 0, 0 (0 ⁄ 1) (1 ⁄ 1) (1 ⁄ 3)
GMFCS III 0, 0 (2 ⁄ 1) (1 ⁄ 1) 0, 0 0, 0 (3 ⁄ 2)
GMFCS IV (2 ⁄ 0) (1 ⁄ 1) 0, 0 0, 0 (1 ⁄ 0) (4 ⁄ 1)
GMFCS V (2 ⁄ 0) 0,0 (2 ⁄ 2) (0 ⁄ 2) (2 ⁄ 2) (6 ⁄ 6)
F, female; M, male; GMFCS, Gross Motor Function Classiﬁcation System.
Table III: Bladder category by type of cerebral palsy, Gross Motor Function Classification System (GMFCS) level, and sex for individuals with urinary
ICS nomenclature Diplegia (n=9) Spastic quadriplegia (n=26) Total (n=35)
GMFCS level I II III II III IV V
Neurogenic detrusor overactivity with sensation 3M 1F 1M 1F, 2M 1F, 1M 3F, 1M 4F, 3M 21 (10F, 11M)
Neurogenic pelvic ﬂoor overactivity upon voiding 0 1F, 1M 0 1F 1F F1, 1M 3F, 2M 12 (7F, 5M)
Neurogenic detrusor overactivity without sensation 0 2F, 2M 0 1M 2F, 1M F1 1F, 2M 12 (6F, 6M)
Neurogenic detrusor underactivity 0 0 0 0 0 0 1F, 1M 2 (1F, 1M)
An individual can be classiﬁed into more than one bladder category. ICS, International Continence Society; F, female; M, male.
CP and Neurogenic Bladder Kevin P Murphy et al. 947
activity and neurogenic pelvic ﬂoor overactivity upon voiding
was slightly more common in individuals showing increased
functional disability. In the two individuals with neurogenic
detrusor underactivity, maximal bladder capacity at leak point
was measured at 525cm
respectively. No other
appreciable differences of bladder category could be identiﬁed
across GMFCS levels, sex, or type of CP.
Figure 2 outlines in general the treatment pathway
followed. A Functional Toileting Review (FTR), was com-
pleted with all patients allowing a more complete understand-
ing of the toileting process and environment. This included
physical, occupational, and nursing assessments where needed
and, on occasion, an in-home site visit with equipment review.
The m edications were given on a schedule every 8 hours,
which was documented by parents, family, or personal care
attendants. Hyoscyamine sulfate was given to two patients
who did not respond to oxybutynin and one child with mild
diplegia (GMFCS level II) at a dose of 0.125mg every 8 hours.
The second patient was an adult with non-ambulatory spastic
quadriparesis (GMFCS level V ) w ho was given a dose of
0.25mg every 8 hours per elixir through his gastrostomy tube.
Twenty-six patients required oxybutynin medication, three of
whom also required desmopressin acetate and pseudoephe-
drine hydrochloride. The dose of desmopressin acetate was
0.6mg at the hour of sleep and pseudoephedrine hydrochlo-
ride 30mg by mouth twice per day. Six people responded to
alterations of toileting schedule or environment, with one per-
son using behavior modiﬁcation. Three used a voiding alert
system, which involved an enuretic alarm attached into the
peroneal padding, alerting the patient and care providers when
urine ﬂow occurred. Based on this system, urination became
predictable and allowed the person to go to the toilet 30 minutes
before the predicted void ⁄ alarm, providing continence. One
person required intermittent catheterization. Three needed an
indwelling Foley catheter, one suprapubic, all by the choice of
patient, family, or guardian.
Negative outcomes were seen in only two people, one with
moderate diplegia (GMFCS level III) who also had a signiﬁ-
cant behavioral disorder and difﬁculty complying with any
form of toileting intervention. This person was in a main-
stream elementary school classroom less than 50% of the time.
The second individual with a negative outcome had spastic
quadriplegia (GMFCS level V). This individual had received
20% or less mainstream elementary education and the family
requested no indwelling catheter system. One other person
from the subgroup with urinary dysfunction was lost to
follow-up, having spastic quadriparesis and being in GMFCS
Positive outcomes were identiﬁed in 32 individuals of the
bladder subgroup (91%) and across all educational and voca-
tional levels. Twenty of these individuals required special edu-
cational services. Four people enjoyed self-sustaining
competitive employment and living independently in the com-
munity. These individuals had educational levels beyond high
school, three with college degrees and one with vocational
training. Positive outcomes did not seem to relate to mobility
status or GMFCS levels.
Thirty-four of the 35 individuals with SNB were carefully
followed with outpatient visits every 6 months. The one per-
son lost to follow-up moved out of our region within
6 months of his initial evaluation and urodynamic studies.
This person had achieved total continence on oxybutynin
medication without concerning side effects. One individual
with severe CP (age 44y; GMFCS level V) obtained conti-
nence within the ﬁrst 6 months of treatment only to become
incontinent again approximately 1 year later. A cervical
Monitor for upper tract
Oxybutynin (average per day):
Age 12 and under, 12.5mg
Age 13 to 19, 1mg
Age 20 and over, 17.5mg
Seating and positioning adjustments with
Biofeedback and relaxed toileting
Management of spasticity/hypertonicity of
Figure 2: Treatment pathways. NDO, neurogenic detrusor overactivity; NDU, neurogenic detrusor underactivity; NPFOV, neurogenic pelvic floor overactivity
when voiding; ICC, intermittent clean catheterization; FTR, functional toileting review.
948 Developmental Medicine & Child Neurology 2012, 54: 945–950
myelopathy was diagnosed by magnetic resonance imaging at
that time. Subsequent neurosurgical decompression with
spinal fusion resulted in resumption of continence during the
The retrospective limitations of the study are noted along
with any practice bias of our rehabilitation medicine team.
SNB was identiﬁed in 16.4% of our sample of people with
CP. The percentage is probably higher in the overall popula-
tion if asymptomatic individuals were included along with
those who could not communicate, and may approach 30%
as discussed in other studies.
Two main peaks of presenta-
tion of patients were identiﬁed: between the ages of 6 and
10 years, and after the age of 30 years. One might assume
the possibility that a smaller bladder with n eurogenic detru-
sor overactivity at a young age can eventually become over-
stretched and display neurogenic detrusor underactivity with
increased age in some people. The result may be inconti-
nence occurring again after the age of 30 years. This appears
consistent with previous reports in the literature
help explain why approximately one-third of this group had
previously been dry before developing symptoms of retention
Eleven of the 75 children studied between the ages of six
and ten had urinary symptoms (approximately 15%). This is
comparable to able-bodied children in the general population
who can present with urinary symptoms including frequent
daytime voiding in 10 to 20%.
Roijen et al., in a study of
601 patients with CP, demonstrated delayed achievement of
continence in those with CP compared with typically develop-
ing children and adolescents.
Ozturk et al.
nence rates of patients with CP (n=45) with those of typically
developing children (n=37). The mean age for nocturnal conti-
nence was 47 months for children with CP and 27 months for
able-bodied peers. It is possible that with further growth and
maturity, many of the children aged 10 and under in this study
could have achieved continence spontaneously on their own.
Some of the children may have also had some element of func-
tional voiding behavior relating to emotional stressors and ⁄ or
nocturnal deep-sleeping patterns.
A surprising observation to us was that mobility appeared to
have little consequence on achieving continence. This is con-
sistent with previous studies
whereby functional communi-
cation and alterations of environment, equipment, and stafﬁng
proved essential in maintaining daily continence. As long as
the individual could communicate the need to toilet and some-
one was available to assist within an appropriate environment,
continence was achieved. The fact that all people in this study
with incontinence had bilateral physical involvement remains
an enigma. This has also been noted in the literature.
bly plasticity of the central nervous system, with the unin-
volved side assuming more control over the bladder during
the developmental years, could help explain the continence
pattern seen in those with hemiparesis.
studied 29 patients with CP aged 3 to 53 years
with a mean age of 16.1 years. All patients were hospitalized
in the orthopedic department either for physiotherapy or for
orthopedic surgery. Urinary symptoms and pathological
urodynamic ﬁndings increased along with the degree of motor
functional impairment shown by GMFCS level. Pathological
urodynamic ﬁndings could be found in both symptomatic and
asymptomatic patients. In the six patients without symptoms
of urinary dysfunction, no one was classiﬁed in GMFCS levels
IV or V. In the 23 patients with symptoms of urinary dysfunc-
tion, no patient was classiﬁed in GMFCS level I. On further
review though, two patients in GMFCS level I were reported
with diurnal frequency (up to 10 voidings per day) and noctur-
nal frequency of two vo idings per night. These two patients
would have been considered symptomatic in our study for fre-
quency, at least on a diurnal basis. With this in mind, we
would consider our present study consistent with that of Bross
as displaying urinary dysfunctional voiding throughout
all levels of GMFCS. Further consistency with Bross et al.
shown by retention in those individuals with increased physi-
cal involvement (GMFCS levels IV and V).
The prevalence of upper urinary tract pathology in our
study sample was low. Only one person (GMFCS level V)
was found to have upper tract involvement including vesico-
ureteral reﬂux and hydronephrosis. This person showed
improvements, including resolution of urinary tract infections
and stability of the upper urological anatomy, with placement
of an indwelling Fo ley catheter. The prevalence of upper
urinary tract ﬁndings in our CP sample is consistent with
It also suggests that upper urinary
tract screening is not a necessary routine in the absence of
retention, urinary tract infection, stones, or other associated
SNB is not uncommon in individuals with CP, especially in
those with bilateral physical involvement.
has been documented clearly across the lifespan, ed ucational
spectrum, sex, and functional levels. The fact that we had three
individuals in the study with SNB educated at college level
and beyond shows that urinary incontinence in this population
is not a problem displayed solely by individuals with intellec-
As recognized by Borzyskowski
and Sibel et al.,
nence achieved is not just a study of central nervous system
integrity and bladder physiology, but that of cognition, learn-
ing abilities, behavior, and the careful functional review of the
entire toileting process. Such a functional review needs to
include basic communication, mobility, management of spas-
ticity, equipment, stafﬁng, funding, and the entire team inter-
vention common to the rehabilitation professional. It appears
that when such a review has occurred and basic communica-
tion threshold identiﬁed in the individual with CP, high rates
of urinary continence can be anticipated with conservative
It is our feeling t hat continence of urine, part of basic
human dignity, should not be denied to anyone within the
context of patient-centered, professional, medical, and surgical
care. Our hope is that our study and others to follow will help
facilitate such dignity while encouraging a lifetime care
approach to this problem of young and old.
CP and Neurogenic Bladder Kevin P Murphy et al. 949
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