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European Journal of Trauma and Emergency Surgery (2021) 47:1591–1598
https://doi.org/10.1007/s00068-020-01319-y
ORIGINAL ARTICLE
Lagos state ambulance service: aperformance evaluation
ChinmayeeVenkatraman1· AinaOlufemiOdusola2· ChenchitaMalolan1 · OlusegunKola‑Korolo3·
OluwoleOlaomi4· JideIdris3· FiemuE.Nwariaku1
Received: 6 September 2019 / Accepted: 4 February 2020 / Published online: 10 March 2020
© The Author(s) 2020
Abstract
Objectives The mortality rate from road traffic accidents (RTAs) in Nigeria is almost double that of the USA. In Nigeria,
the first emergency medical services (EMS) system was established in March 2001, The Lagos State Ambulance Service
(LASAMBUS). The objectives of this study are to (1) determine the burden of RTAs in Lagos, (2) assess RTA call outcomes,
and (3) analyze LASAMBUS’s response time and causes for delay.
Methodology We reviewed completed LASAMBUS intervention forms spanning December 2017 to May 2018. We cat-
egorized the call outcomes into five groups: I. Addressed Crash, II. No Crash (False Call), III. Crash Already Addressed,
IV. Did Not Respond, and V. Other. We further explored associations between the (1) causes for delay and outcomes and
(2) response times and the outcomes.
Results Overall, we analyzed 1352 intervention forms. We found that LASAMBUS did not address 53% of the RTA calls
that they received. Of this, Outcome II. No Crash (False Call) accounted for 26% and Outcome III. Crash Already Addressed
accounted for 22%. Self-reported causes for delay were recorded in 180 forms, representing 13.7% of the RTA burden. Traffic
congestion accounted for 60% of this distribution.
Conclusion LASAMBUS response rates are significantly lower than response rates in high-income countries such as the USA
and lead to increased RTA mortality rates. Eliminating causes for delay will improve both LASAMBUS effectiveness and
RTA victims’ health outcomes. Changing the public perception of LASAMBUS and standardizing LASAMBUS’ contact
information will aid this as well.
Keywords Road traffic injuries· Mortality· Nigeria· Emergency medical services· Prehospital care
Electronic supplementary material The online version of this
article (https ://doi.org/10.1007/s0006 8-020-01319 -y) contains
supplementary material, which is available to authorized users.
* Chenchita Malolan
chenchita.malolan@utsouthwestern.edu
Chinmayee Venkatraman
chinmayee.venkatraman@utsouthwestern.edu
Aina Olufemi Odusola
f.odusola@gmail.com
Olusegun Kola-Korolo
dlasambus@gmail.com
Oluwole Olaomi
wole_olaomi@yahoo.com
Jide Idris
jide.idris1@gmail.com
Fiemu E. Nwariaku
fiemu.nwariaku@utsouthwestern.edu
1 Office ofGlobal Health, Department ofSurgery, University
ofTexas Southwestern Medical Center, 5323 Harry Hines
Boulevard, Dallas, TX75390, UnitedStatesofAmerica
2 Department ofCommunity Health & Primary Health Care,
Lagos State University Teaching Hospital, 1—5, Oba
Akinjobi Road, Ikeja,Lagos, Nigeria
3 Lagos State Ministry ofHealth, Block 4, The Lagos State
Government Secretariat Complex, Alausa, Ikeja,Lagos,
Nigeria
4 Department ofSurgery, National Trauma Centre, National
Hospital Abuja, Plot 321, Central Business District, FCT,
Abuja, Nigeria
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1592 C.Venkatraman et al.
1 3
Introduction
The global prevalence of road traffic accidents (RTAs) and
road traffic injuries (RTIs) is steadily increasing. According
to the World Health Organization, RTAs killed 1.35mil-
lion people in 2018 and injured an additional 50million [1].
RTIs are now the leading cause of death among children
and young adults aged 5–29years, overtaking HIV/AIDS,
diarrheal diseases, and tuberculosis [2]. This burden is dis-
proportionately higher in low- and middle-income coun-
tries (LMICs), with 93% of road traffic fatalities occurring
in these settings [1, 3]. Globally, road traffic fatality rates
are the highest in the African continent at 26.6 deaths per
100,000 [4]. Nigeria has an annual mortality rate of 20.6
deaths per 100,000 people due to RTAs, in comparison to
the USA at 10.8 deaths per 100,000 people and the UK at
2.9 deaths per 100,000 people [5].
Lagos is the most densely populated state in Nigeria
(6710 population per km2), which is more than three times
the population density of New Jersey (1947 population per
km2), the most densely populated state in the USA [6, 7].
Lagos is divided into 20 local government areas (LGAs) and
has an intricate system of road networks managed by vari-
ous levels of government. Trunk A roads are maintained by
the federal government, Trunk B by the state government,
and local roads by the local government with aid from the
state government [8]. Additionally, there are several major
intra- and interstate expressways throughout Lagos. Coor-
dinating infrastructure management within these levels of
government is difficult and often leads to poor road condi-
tions [8]. One major concern is the presence of numerous
potholes across all types of roads, sometimes large enough
to cover more than half the width of the road [9]. In fact, in
2012, 81% of the roads examined in Lagos had more than 100
potholes, resulting in unsafe road conditions [9]. The Lagos
State Public Works Corporation (PWC) is the government
entity “responsible for routine repair and rehabilitation of
road across the state, such that they remain motorable all
year round” [10]. It coordinates road reconstruction across
the state and works with local governments to identify spe-
cific issues. One major issue that it encounters is the weather
in Lagos, specifically the rainy season. The Lagos climate
is generally high in humidity with high temperatures, with
the exception of a rainy season from June to October [11].
Not only does this primarily affect the repairs of potholes
in the roads, but it also creates drainage issues that further
delay these repairs, affecting motor vehicle and pedestrian
travel, RTA rates, RTA response times, and prehospital care
delivery [12].
Emergency medical services (EMS) systems are an
essential part of prehospital management of RTIs. Increased
EMS response times have been proven to be associated with
higher mortality rates in rural communities [13]. The median
urban response time in Africa is 15min (6–120min), which
is more than double the median urban response time in the
USA [14, 15]. Currently in Africa, there are 25 EMS systems
in 16 countries, representing merely 30% of the continent
[15]. West Africa is especially underrepresented with EMS
systems only present in Ghana and Nigeria [15]. Oftentimes,
the lack of a national prehospital trauma care system results
in EMS systems established by state governments or private
corporations. This, in turn, leads to a lack of standardized
prehospital care delivery within the country [16]. In fact,
a majority of these systems only provide ambulance trans-
port services as opposed to both transport and paramedic
services [16]. For example, an EMS system in Imo State is
staffed entirely by volunteers who are not trained to provide
prehospital care [16]. Contrastingly, in Lagos State, the state
government has invested in the Lagos State Ambulance Ser-
vice (LASAMBUS), which is better equipped to attend to
emergency situations [16].
LASAMBUS was established in Lagos in March 2001
as the first EMS system in Nigeria [17]. There are three
main EMS systems in Lagos: LASAMBUS, Lagos State
Emergency Management Agency (LASEMA), and Lagos
Response Unit (LRU). LASAMBUS uses standard ambu-
lances and there are currently 25 ambulance stations in the
state. When someone calls for an ambulance in the event
of an RTA or other accidents, the call is received by a call
center in Lagos, which dispatches the ambulance closest
to the crash site. Concurrently, LASAMBUS completes an
intervention form detailing the response from when the call
was received to when it was concluded. LASAMBUS then
transports the RTA victims to a nearby hospital. Lagos has
two main trauma care centers, The Lagos State Accident
and Emergency Centre and the Burns and Trauma Unit at
Gbagada General Hospital. LASAMBUS receives 11,126
calls annually, ranging from trauma cases and general medi-
cal cases to hospital transfers. In 2012, an assessment of
LASAMBUS found that RTAs accounted for the largest
proportion of calls received [17]. Additionally, traffic con-
gestion and community disturbance were listed as causes for
delay that LASAMBUS encountered [17]. The objectives of
this study were to:
1. Determine the burden of RTAs in Lagos State.
2. Assess the RTA call outcomes.
3. Analyze LASAMBUS’s response time and causes for
delay.
Methods
This is a retrospective, cross-sectional study. We received
completed LASAMBUS intervention forms that were clas-
sified as RTA calls from December 2017 to May 2018 from
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1593Lagos state ambulance service: aperformance evaluation
1 3
the Lagos State Ministry of Health. We omitted 10.1% of
the forms based on our exclusion criteria, which included
any LASAMBUS call that were misclassified as an RTA,
any that were not in the study time frame, or any thatwere
intervention forms in which the first and second pages of
the form did not pertain to the same call scenario (missing
pages, blank pages, etc.). After applying our exclusion cri-
teria, we reviewed 1352 intervention forms.
Electronic supplementary material: Appendix A is a
blank version of the intervention form. We focused our
analyses on the following sections:
• Date of Call
• Timing of Call
• Demographics of the Victim
• Distribution of Cases
• Intervention and Monitoring
• Trauma Prompts
• Causes for Delayed Response
• Triage Revised Trauma Score
• Remarks of the LASAMBUS Crew
To determine the outcomes of the calls received, we
reviewed the “Remarks” section of the forms, which was
written as a narrative. We categorized the responses into
five outcomes:
I. Addressed Crash.
II. No Crash (False Call).
III. Crash Already Addressed.
IV. Did Not Respond.
V. Other.
We further categorized certain outcomes based on com-
mon findings. The forms were hand-written and while we
acknowledge the possibility that forms could have been
illegible, we did not encounter any illegible forms.
An electronic version of the LASAMBUS form was cre-
ated to manage study data using the REDCap electronic
data capture tool [18]. To this form, we added the Out-
comes section, a second Trauma Prompts section, and a
second Causes for Delay section. The latter two sections
were created to account for those forms that had a spe-
cific trauma prompt or cause for delay mentioned in the
“Remarks”, but were not appropriately marked in the
respective sections of the intervention forms. Since we
were able to accurately identify these, we combined the
data from the form along with what should have been
marked initially for both the Trauma Prompts section and
the Causes for Delay section for all subsequent analyses.
Response Time was defined as the difference between when
the call was received and when LASAMBUS arrived at the
RTA site. We encountered some missingness in the data
with regard to our response time analyses. We employed a
pairwise deletion analysis technique to account for those
observations that only had a call received time or a time
when LASAMBUS arrived at the RTA site, for which
we could not calculate a response time. We were able to
successfully calculate a response time in 82.6% of cases.
Stata 15 was used to conduct descriptive statistical analysis
and logistic regression analysis where α = 0.05. Bivariate
analyses were conducted to assess the association between
Causes for Delay and each Outcome. Multivariate regres-
sion analyses evaluated the relationship between significant
Causes for Delay and all Outcomes, and the relationship
between Response Time and all Outcomes.
The University of Texas Southwestern Medical Center’s
Institutional Review Board approved this study as non-
regulated research, citing the U.S. Department of Health
& Human Services’ regulation 45 CFR 46.102. The NIH
Partnerships to Develop Injury Research Capacity in Sub-
Saharan Africa grant (5D43TW010463-03) supported this
research.
Fig. 1 Monthly distribution of RTA calls in Lagos State received by
LASAMBUS, December 2017–May 2018
Table 1 Descriptive characteristics of RTAs attended to by LASAM-
BUS, December 2017–May 2018
Total sample
(n = 1352) n
(%)
Age (years) (n = 437) 34.0 (3.0–85.0)
Gender (n = 466)
Male 340 (73.0)
Female 126 (27.0)
Response time
“Call received” to “arrived at scene” (minutes) 17.0 (7.0–60.0)
Distribution of outcomes
Outcome I: addressed crash 502 (37.1)
Outcome II: no crash (false call) 351 (26.0)
Outcome III: crash already addressed 293 (21.7)
Outcome IV: did not respond 17 (1.3)
Outcome V: other 189 (14.0)
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1594 C.Venkatraman et al.
1 3
Results
LASAMBUS received 1352 RTA calls between December
2017 and May 2018. Figure1 shows the monthly distribution
of calls received during the study period, with an average of
226 calls per month. Table1 displays the descriptive charac-
teristics of the dataset. The median age of the RTA victims
was 34.0years (SD 12.0) and the majority (73%) were male.
The average response time of each LASAMBUS call was
17.0min (7–60min). We were able to ascertain the outcome
of every call, as there were no illegible forms. LASAMBUS
only addressed 37.1% of the calls that they received (Out-
come I). Outcome II: No Crash (False Call) and Outcome
III: Crash Already Addressed represented almost 50% of
the call outcomes (Fig.2). We found common responses in
these categories that we further coded into subcategories
(Fig.3). Outcome II: No Crash (False Call) defined calls in
which no crash was sighted, with or without witness cor-
roboration. Only 9.4% of the false calls had witness cor-
roboration. Within Outcome III: Crash Already Addressed,
the most common sub-category was “Unknown” (81.9%),
in which the only description LASAMBUS gave was “crash
was already addressed”. This was followed by “Responded
to by Police” (3.1%) and “Self-Evacuated” (2.7%). “Miscel-
laneous” responses for Outcome III included “attended to
by LASEMA” and “attended to by LRU”. Within Outcome
IV: Did Not Respond, “crew was asked to be on standby”
represented 41.4% of the calls. “Miscellaneous” responses
included “no fuel” and “no ambulance available”. Within
Outcome V: Other, “found RTA, no injuries” (36.5%) and
“found RTA, victim already died” (26.5%) accounted for
over half of the responses.
Table2 shows the distribution of self-reported causes
for delay and the Fisher’s exact analyses for Causes for
Delay and all Outcomes. Causes for delay were reported
in 180 forms, representing 13.7% of the RTA burden. Traf-
fic congestion accounted for 60% of the distribution, fol-
lowed by poor description (17.8%) and proximity (7.2%).
Furthermore, traffic congestion (p = 0.001), poor access
(p < 0.0001), and community disturbance (p = 0.016) all had
a significant association with the Outcomes. Table3 shows
the multivariate regression analyses for (1) Traffic Conges-
tion and all Outcomes and (2) Poor Access and all Out-
comes. We did not conduct regression analyses for causes
for delay if the association between the cause for delay and
all outcomes was not significant in the Fisher’s exact analy-
ses or ifthere were less than five observations of a particu-
lar cause for delay, which is not compatible with regression
analysis. For Traffic Congestion, we found a significant
association with Outcome III (p = 0.011) and Outcome IV
(p = 0.026). For Poor Access, we only found a significant
association with Outcome IV (p = 0.001). Table4 shows the
multivariate regression analyses for Response Time and the
Outcomes, which did not yield any significant associations.
Discussion
Through this study, we identified three key findings:
1. There was variance in the monthly distribution of RTAs
to which LASAMBUS attended.
2. LASAMBUS did not address more than 50% of the RTA
calls they received.
3. There were significant associations between specific
Causes for Delay and Outcomes—a. Poor Access and
Outcome IV: Did Not Respond, b. Traffic Congestion
and Outcome III: Crash Already Addressed and c. Traf-
fic Congestion and Outcome IV: Did Not Respond.
Pre-hospital care management is integral to improving
patient outcomes, particularly victims of RTAs. Previous
studies have shown that mortality rates could be up to 5.5
times higher in RTA victims without pre-hospital care [19].
By characterizing the cases attended to by LASAMBUS,
identifying the outcomes of the calls, and recognizing the
scenarios leading to these outcomes, we are better informed
about the pre-hospital care management that LASAMBUS
provides.
A number of our findings were consistent with existing
literature. Our victim population demographics resembled
those reported by the World Health Organization, other stud-
ies in Nigeria, and in other LMICs such as Iran [3, 20, 21].
With regard to the second finding, our study showed that
LASAMBUS attended to less than half of the RTA calls
that it received. Similarly, a 2017 single-institution study
revealed that, of all the RTAs that came into the emergency
department of a tertiary health facility, the Lagos State
Fig. 2 Distribution of outcomes of RTA calls received by LASAM-
BUS, December 2017–May 2018
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1595Lagos state ambulance service: aperformance evaluation
1 3
University Teaching Hospital (LASUTH), less than 3% were
brought in by LASAMBUS [22].
The outcomes of the calls that LASAMBUS received
provide insights into the burden of RTAs, notably the
prevalence of false calls and the RTAs that had been
addressed prior to LASAMBUS’ intervention. There is a
dearth of literature concerning false calls in LMICs; how-
ever, they have been identified as a challenge in an EMS
Fig. 3 Distribution of responses within outcomes of RTA calls received by LASAMBUS, December 2017–May 2018
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1596 C.Venkatraman et al.
1 3
study conducted in Ghana [23]. With regard to RTAs that
were already addressed prior to LASAMBUS’ arrival,
findings in other LMICs reinforce the idea that EMS ser-
vices do not account for many of the cases brought into the
hospital [24]. It is important to acknowledge that not all
RTAs resulted in injury and that there were also records in
which the victims had already died prior to LASAMBUS’
intervention.
Ambiguity around how to contact EMS systems, like
LASAMBUS, can exacerbate the problem. A survey done
in 2017 showed that the majority of the public in Nigeria did
not know the appropriate emergency numbers to call, and
that trust in EMS systems is low [25]. The Lagos State Gov-
ernment website itself lists six different telephone numbers
for LASAMBUS [26]. Furthermore, the existence of other
emergency response systems, such as LASEMA or the LRU,
can confuse both victims of trauma and innocent bystand-
ers who are trying to help. Both of these EMS services also
have multiple associated numbers and are listed ahead of
LASAMBUS in the list of emergency telephone numbers
on the Lagos government website [26]. The uncertainty of
whom to call can result in LASAMBUS not being able to
address the RTA or being delayed in its response. There
has been an attempt to standardize and streamline the pro-
cess with the introduction of an emergency communication
network and call center [25]. However, multiple toll-free
numbers (112, 123, etc.) continue to be advertised, imped-
ing these efforts.
Our median response time from when LASAMBUS
received the call to when they arrived on the scene (17min)
was comparable to the response time of ambulances in
Accra, Ghana and is only 2min longer than the median
urban response time across all African EMS systems [15,
27]. Lower response times have been shown to be associated
with better patient outcomes and higher chances of survival
and is a crucial part of pre-hospital care management [27].
Findings from a study conducted in Spain in 2010 estimated
that a 10min reduction in response time could result in a
33% decrease in mortality rates in RTAs [28]. While fur-
ther analysis into response time did not yield any significant
associations, it is encouraging to note that our response time
is similar to other LMICs in Africa. However, LASAMBUS
has a self-identified goal of 10min, which is 7min faster
than the current median response time, and highlights room
for improvement.
The use of sirens by non-EMS vehicles is a challenge
that LASAMBUS encounters and one that could add to this
disparity. The inappropriate use of sirens, by governmental
or military vehicles can desensitize the public, making them
more likely to ignore LASAMBUS or other EMS vehicle
sirens. Specific rules prohibiting the use of sirens by those
other than emergency professionals can help to alleviate this.
Also, the number of ambulance stations has increased from
18 in 2006 to 25 currently. Continuing to increase the num-
ber of ambulance stations will also decrease response time
by increasing the proximity to RTA sites.
In relation to the third finding, we observed that a sub-
stantial proportion of the causes for delay reported by
LASAMBUS was concerned with the public infrastruc-
ture, namely traffic congestion or poor access to RTA
(65%), both of which were also significantly associated
with specific outcomes. One explanation for these causes
for delay could be the poor state of roads in Lagos. Nar-
row roads, potholes, or inadequate street lighting are all
Table 2 Evaluating the bivariate relationship between each cause for
delay and all outcomes (n = 180)
* p value < 0.05
Cause for delay Distribution (%) Fisher’s exact test
Traffic congestion 108 (60.00) 0.001*
Poor description 32 (17.78) 0.190
Proximity 13 (7.22) 0.226
Poor access 9 (5.00) 0.000*
Faulty ambulance 9 (5.00) 0.100
Community disturbance 4 (2.22) 0.016*
Other 4 (2.22) 0.105
Weather 1 (0.56) 0.629
Table 3 Evaluating multivariate relationship between significant
causes for delay from Table2 and all outcomes
* p value < 0.05
Outcomes Causes for delay, p value
Traffic congestion Poor access
Outcome I: addressed crash Ref
Outcome II: no crash (false call) 0.060 0.784
Outcome III: crash aready
addressed
0.011* 0.899
Outcome IV: did not respond 0.026* 0.052
Outcome V: other 0.001* 0.816
Table 4 Evaluating multivariate relationship between response time
and all outcomes
* p value < 0.05
Outcomes Response
time, p
value
Outcome I: addressed crash Ref
Outcome II: no crash (false call) 0.0925
Outcome III: crash already addressed 0.600
Outcome IV: did not respond 0.380
Outcome V: other 0.185
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1597Lagos state ambulance service: aperformance evaluation
1 3
recorded problems in Lagos and can increase response
time and traffic congestion, and obstruct access to the
RTA [29]. In 2017, the Governor of Lagos outlined road
construction and maintenance as a key priority in the
annual budget [30]. The increasing prevalence of vehicle
breakdowns and the influx of commercial buses and trucks
amplify traffic congestion and its associated consequences
as well [31]. In 2018, the Lagos State Traffic Management
Agency (LASTMA) found that vehicular breakdowns in
Lagos accounted for 70% of the traffic gridlocks in the
state [31]. They theorized that strengthening the relation-
ship between the public and LASTMA officials could more
efficiently and effectively resolve these breakdowns [31].
One limitation of this study was incomplete forms, in
which some fields were left blank. Examples of these fields
include age and LGA. Despite this, we were able to suc-
cessfully identify an outcome for all 1352 forms. In the
future, we hope to link intervention forms to the ambu-
lance points from which they were created and map the
RTAs across LGAs. This will help to provide a more accu-
rate picture of the distribution of RTA outcomes across
Lagos. We are also in the process of exploring the causes
for delay and response times in each LGA to detail specific
points of intervention by LGA and ambulance point. Addi-
tionally, our future efforts will focus on piloting electronic
data collection in high call-volume ambulances. We hope
that this will improve the quality of data collection and
standardize the intake process of LASAMBUS, to better
track and improve victim outcomes.
Conclusion
While the RTA mortality rate in Nigeria is increasing
annually, Lagos is especially affected as one of the most
populous states in Nigeria. LASAMBUS faces various
obstacles in attending RTAs and its current response rate is
alarming, playing a part in the increasing mortality rates.
Focusing attention on reducing the occurrence of false
calls, improving road conditions, and standardizing the
contact methods for LASAMBUS will help to make this
better. To achieve this, a collective effort has to be made
by LASAMBUS, the Lagos Ministry of Health, and the
Lagos Government. Future research on RTA patterns and
victim outcomes by LGA will also help to further under-
stand the circumstances influencing RTA mortality rates.
Acknowledgements This research was supported by the National Insti-
tutes of Health Partnerships to Develop Injury Research Capacity in
Sub-Saharan Africa grant (5D43TW010463-03).
Author contributions Ms. CV, Ms. CM, and Dr. FEN conceptualized
the study, wrote the manuscript, and saw the project to completion. Dr.
AOO, Dr. OK-K, and Dr. JI provided the data (completed Lagos State
Ambulance Service intervention forms) from the Lagos State Ministry
of Health in Nigeria. Dr. OO reviewed and contributed to the text of
the manuscript. All authors read and approved the final manuscript.
Compliance with ethical standards
Conflict of interest Chinmayee Venkatraman, Aina Olufemi Odusola,
Chenchita Malolan, Olusegun Kola-Korolo, Wole Olaomi, Jide Idris,
and Fiemu E. Nwariaku declare that they have no conflict of interest.
Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
included in the article’s Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
the article’s Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/.
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