Research Paper Scenario On Thursday morning, John, an XYZ university employee, noticed a warning message on his computer saying that the system has been at

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Scenario

On Thursday morning, John, an XYZ university employee, noticed a warning message on his computer saying that the system has been attacked by a worm Win32.VB. Even though the antivirus software was present in the system, the software failed to detect the new worm because it was not updated to the latest version. When John tried to open his e-mail, he experienced a slow internet connection. He noticed there were some unusual file names in the disk. John immediately informed his friend Bob, who was also an XYZ employee, of the problem. Bob checked his computer in his office and experienced the same problem as John. John and Bob checked several computers in the laboratories, and found that Win32.VB worm had infected many other computers in the laboratory. They contacted the system administrator of the XYZ University. The system administrator checked the computers in the laboratory and reported the incident to the incident response team. The system administrator also checked the computers in other laboratories. As a result of the worm attack the activities in the XYZ University laboratory were suspended for a day, which caused a great inconvenience.

 

Case Objectives:

  • Create an incident response plan which      is accompanied by a forensic plan please refer to NIST specifications.
  • Must include penetration testing and      forensics procedures etc.
  • Diagram of the attack
  • Identify the vulnerabilities

     

Requirements:

• Minimum of 1,250 words / Maximum 1,800 words (Double spaced)

• APA style

• At least 7 works cited 

• At least 5 of your references have to be scholarly peer-reviewed articles

• Research paper will be checked for plagiarism so be sure to correctly cite your sources!

80/20 rule for all submissions

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DE GRUYTER International Journal of Adolescent Medicine and Health. 2020; 20180179

Review Article
Margaret R. Spencer1 / Sierra Weathers1

Trends and risk factors of adolescent opioid
abuse/misuse: understanding the opioid
epidemic among adolescents
1 Simmons College, 300 The Fenway, Boston, MA 02115, USA, E-mail: maggie.spencer86@gmail.com

Abstract:
Over the past decade, opioid abuse/misuse has grown from a local problem into a national crisis, causing
the U.S. Health and Human Services (HSS) to declare a public health emergency. The number of those dying
from opioid abuse has increased, especially among adolescents. Since 2014, death rates due to opioid overdose
have been highest in persons aged 15–19 years. This systematic review examines past and present research
concerning opioid abuse/misuse and seeks to bring more attention to the growing opioid epidemic affecting
adolescents aged 12–25 years nationwide. Keywords such as “adolescent”, “opioid”, “overdose”, “opioid mis-
use”, and phrases including “opioid use and race”, “income status and opioids”, were used to find common
demographic trends which can be attributed to this population. The process of gathering and disseminating
information currently available on this subject helps highlight a somewhat taboo subject involving vulnerable
members of our community. It is imperative that healthcare providers, in particular, those who treat adoles-
cents, have access to current research and resources that support efforts to combat this persistent issue. In ad-
dition, this information will prove useful to those who have the ability to change policies and how this current
crisis is being managed. Results from the research indicate that opioid abuse/misuse in adolescents is rising
and race, gender and income play a role in the abuse/misuse of opioids. Likewise, the research proves that
more opportunities for education and access to adequate treatment are paramount to ending the prevalence of
opioid abuse/misuse.
Keywords: adolescent, gender, nonmedical opioid use, opioid, opioid misuse, overdose, race, teenagers, treat-
ment
DOI: 10.1515/ijamh-2018-0179
Received: August 8, 2018; Accepted: September 9, 2018

Introduction

From 2000 to 2016 more than 600,000 people died due to drug overdoses, while the majority of overdose re-
lated deaths, about 66%, were due to opioids [1]. Each day more than 1000 people are treated in emergency
departments for opioid related problems [1]. Unfortunately, more than 140 people die each day due to a drug
overdose, and 91 of those are specifically related to opioids [2]. In 2015, 52,404 Americans died from drug over-
doses, and at least 64,000 died in 2016 [3]. Young adults are one of the largest abusers of opioids [4]. In 2014,
more than 1700 young adults, roughly five persons per day, died from a drug overdose; a four-fold increase
from 1999 [4]. In 2015, the death rates in those aged 15–19 for overdoses were the highest for opioids [5].

In addition to the loss of life, the Council of Economic Advisers [6] estimated the economic cost of the opioid
crisis was $504 billion in 2015. In 2017, the U.S. Health and Human Services (HHS) declared a public health
emergency related to the national opioid crisis [2]. By declaring a public health emergency, the HHS is able
to accelerate the appointment of specialized personnel to address the opioid emergency, and work with the
Drug Enforcement Agency to expand telemedicine for certain groups of patients [2]. In 2017, the HHS invested
roughly $900 million in opioid funding to support state and local governments, civil society groups, treatment
and recovery services, first responder training, and to target availability of overdose-reversing drugs [2].

The HHS, in 2017, revealed a five-point opioid strategy which included improving access to preven-
tion, treatment and recovery services, targeting the availability and distribution of overdose-reversing drugs,
strengthening the public health data reporting and collection systems, supporting research on addiction and
pain and advancing pain management practice [2]. This systematic review compiles information related to the
Margaret R. Spencer is the corresponding author.
© 2020 Walter de Gruyter GmbH, Berlin/Boston.

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Spencer and Weathers DE GRUYTER

prevalence, cost, treatment, overdose, abuse/misuse of opioids (prescribed or non-prescribed) among young
adults aged 12–25 years of age. Those aged up to 25 years were included as often they are still receiving health-
care from pediatricians and are also included in the national definitions of “youth” [7]. Specific demographic
trends (age, race, gender and socio-economic status) involving this population will also be identified. The lit-
erature uses both misuse and abuse differently, however, the use of both terms is appropriate. Drug misuse is
using a drug for purposes other than what it was intended for, or not following medical instructions [8]. Drug
abuse is seen in people taking drugs for which they do not have a prescription, taking drugs for the feelings
they experience (such as euphoria), and chronic/repeated use [8]. The key difference between abuse and mis-
use is the person’s intention when taking the drugs [8]. While this is not the first systematic review to be written
regarding adolescents and opioid abuse/misuse, it is important to bring to light the growing opioid epidemic
in order to help gain control of it through dissemination of the research and recommendations.

Materials and methods

To complete a thorough literature review, articles were obtained from search databases embedded within the
Simmons College Library web page. The search engines used for this review included CINAHL, Scopus and
Cochrane. Keywords and phrases used in the search included the following terms: “young adults and opioids”,
“opioids”, “what is young adult opioid use”, “opioid use and race”, “income and opioid use”, “income status
and opioids”, “overdose”, “opioid abuse”, “opioid misuse” and “access and opioids”. Exclusions included the
following: no specific disease state or co-morbidity, no research older than 2005 or language other than English.
Inclusion criteria included articles dating from 2005 to present and evidence-based research.

With increasing coverage and focus being brought to the opioid crisis unfolding in America, the only ap-
propriate response from healthcare providers, and those who are able to affect healthcare practice and law,
is to guarantee that the most up-to-date, synthesized evidence-based research and information is presented to
those prescribing these powerful opioids. The thought is not to stop prescribing these medications, however, to
ensure that the prescriber, and more specifically the pediatrician, is informed of adolescents who are at a higher
risk for opioid abuse/misuse, and also treatment options for those trying break their addiction. The intent of
this literature review was to compile current studies regarding opioid abuse/misuse among young adults, as
well as the common demographic trends related to this population.

Results

In a recent study of opioid injection misuse, researchers sought to obtain information on the magnitude, charac-
teristics, injection practices and syringe sources for people who inject prescription opioids [9]. Those who inject
drugs are at increased risk for other injection-related infections such as endocarditis, substance use disorders
and drug overdoses [9]. The lack of this information limits the implementation of targeted policies and program-
matic initiatives. Data between 2003 and 2014 from the National Survey on Drug Use and Health (NSDUH) were
collected to estimate prescription opioid injection trends, and to examine risky injection practices and syringe
sources associated with prescription opioid injection [9]. This annual survey is conducted by Substance Abuse
and Mental Health Services Administration (SAMHSA) involving non-institutionalized, US civilians aged 12
years and older, and can provide national estimates of illicit drug use – including prescribed drugs, alcohol,
and tobacco [9].

Multivariable logistic regression was used to identify characteristics associated with prescription opioid
injection. Results found that the rate of prescription opioid injection for people age 12 years and older increased
from 1.6 per 1000 in 2003–2005 to 2.7 per 1000 in 2012–2014 [9]. Groups that had greatest risk for opioid injection
included: non-Hispanic Whites, males, those with an annual income less than $50,000, those uninsured or on
Medicaid, and those with a history of heroin, or prescription drug abuse within the last year [9]. Risky injection
practices and/or sharing of needles was also a common finding among people who had a history of opioid
injection misuse [9]. Overall, there has been significant increase in prescription opioid injection misuse in the
USA and research suggests that more evidence-based interventions are needed, more medication-assistance
treatment for opioid use disorders are required and overall, expanded access to comprehensive risk-reduction
services are necessary for those who inject opioids [9].

Sung et al. [10] compiled information from the NSDUH regarding the prevalence of opioid abuse among
adolescents aged 12–17 years. While this is an older article, it serves as good information that an opioid epidemic
was recognized in 2002, and has been growing since. From 1994 to 2001, emergency department admissions
involving oxycodone and hydrocodone increased by 352% and 131%, respectively [10]. An estimated 7.6% of

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DE GRUYTER Spencer and Weathers

adolescents, aged 12–17, years used nonmedical, prescription-type opioids in 2002 [10]. Not surprisingly the
number of opioids being prescribed increased by 376% from 1992 to 2002 [10]. From 1990 to 2002, the prevalence
of opioid abuse among adolescents grew by 618% and an estimated 2.8 million adolescents misused opioids
during their lifetime [10].

Females, older adolescents, Whites, and individuals from lower-income families were among the higher-risk
groups for misuse [10]. The prevalence of opioid misuse is also higher in those who have a history of delin-
quent activities, those who have recent contact with mental health professionals, those who sold illicit drugs,
those who attended religious services infrequently, and most powerfully, among those who used alcohol and
tobacco or misused other prescriptions drugs [10]. Conversely, higher levels of parental involvement, parents
who disapproved of marijuana use, parents who frequently checked on their children and parents who fre-
quently commended their children are all factors that contribute to a significantly lower risk for engagement in
opioid misuse [10].

In 2004, 6.9% of males and 7.8% of females abused opioids [10]. The prevalence use among those aged 12–13
years was 3.0%, aged 14–15 years was 7.5%, and those aged 16–17 years was 11.9% [10]. Whites had a prevalence
of 7.8%, Blacks 5.8%, Hispanics 7.1%, Asians 4.3% and other ethnicities 7.5% [10]. Total family annual income is
a factor which affects prevalence. In families with a total annual income of $19,999 or less, prevalence was 11.1%;
a total annual income of $20,000–$49,999 had a prevalence of 7.8%, and a total annual income of $50,000 and
more was 6.9% [10]. Education level is also associated with misuse. Education levels of eighth grade and lower
had a prevalence of 3.6%, ninth through twelfth grade had a prevalence of 9.7%, and those with some college
education had a prevalence of 18.5% [10]. Overall, almost 2.8 million adolescents in 2002, reported opioid misuse
sometime during their lifetime, compared to 240,000 in 1989 [10]. The increase in opioid misuse prevalence
coincides with the increase in medical use/prescriptions being written for pain management [10]. Adolescent
opioid misusers tend to come from low-income families, have low parental involvement and a positive attitude
towards drugs [10].

Opioid use disorder (OUD) has been found to frequently begin in adolescence and young adulthood; an
estimated 7.8% of high school seniors have reported lifetime nonmedical prescription opioid use, and two-
thirds of those in OUD treatment report their first use was before the age of 25, and one-third reported their
first use before age 18 years [7]. The study, conducted through a retrospective cohort, included youths aged
13–25 years who received an OUD diagnosis between January 1, 2001 and June 30, 2014 [7]. Data was obtained
from de-identified Optum data from a large US commercial health insurer [7]. Variables of interest were pri-
marily in regard to the receipt of buprenorphine or naltrexone, but also included sex, age of OUD diagnosis,
race/ethnicity, metropolitan area, neighborhood educational level and poverty level [7].

During the specified time period of the study 9,710,131 youths aged 13–25 years were identified in the
Optum data; 20,822 of these youths met criteria for an OUD diagnosis [7]. Each subsequent year of the study
the overall diagnosis rate increased; nearly 6-fold from 0.26 per 100,000 person-years in 2001, to 1.51 per 100,000
person-years in 2014 [7]. Among those with an OUD, 65.8% were male, with a mean age of 21.0 years at the time
of the diagnosis, with most youth from a predominantly non-Hispanic White neighborhood [7]. Those with an
OUD were found to more likely be male, or from a metropolitan area, a high education neighborhood, a low
poverty neighborhood, a non-Hispanic White neighborhood, or the Northeast [7].

Buprenorphine or naltrexone was received by 5,580 youth (26.8%) with an OUD within 6 months of their first
diagnosis [7]. Medication receipt increased more than 10-fold from 2002 (3.0%) to 2009 (31.8%); however, multi-
ple factors including younger age, female, Black non-Hispanic or Hispanic ethnicity, and low-middle neighbor-
hood poverty level, all significantly decrease the odds of medication receipt [7]. Those from a non-metropolitan
area; low-middle or low education neighborhood; low-middle, high-middle or high poverty neighborhood;
or from the Midwest were more likely to receive buprenorphine [7]. Naltrexone was commonly prescribed
to younger youth, females, those in metropolitan areas, lower poverty neighborhoods, and higher education
neighborhoods [7].

Overall, only one in four youth received OUD treatment within 6 months of their diagnosis, which leaves a
critical treatment gap [7]. Odds of receiving therapy are lower with younger age, females, Black and Hispanic
youths [7]. Youth with commercial insurance, compared to youth with public insurance, are less likely to receive
addiction treatment [7]. Treatment for adolescents with an OUD is limited; less than one in three specialty drug
treatment programs in the US offers programs to adolescents [7]. Even less are the number of pediatricians
with a waiver to prescribe buprenorphine outside of metropolitan areas, and even scarcer are the number of
pediatricians who even prescribe buprenorphine [7]. It is recommended that access to pharmacotherapy is
expanded so that it addresses the racial/ethnic and gender disparities, and to increase the number of pediatric
addiction subspecialists and pediatricians who able to prescribe buprenorphine [7].

Wu et al. [11] evaluated treatment use and barriers among adolescents with opioid use disorders. While this
article is older, it shows that there was a lack of treatment being sought out and used prior to the opioid epidemic
growing, and that interventions are still needed to increase treatment for opioid abuse among adolescents.

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Spencer and Weathers DE GRUYTER

Opioids, after cannabinoids, are the second most commonly used/abused drug and approximately 10% of
adolescents 12–17 years old have used non-medicinal opioids [11]. Adolescence is a critical time to intervene
to prevent lifelong addictions and the consequences which accompanies them [11]. Opioids have a high abuse
potential, are associated with the highest rate of overdose and mortality, are easier to get, and often require
long-term treatment to break the addiction [11].

In most cases, adolescents will rely on an adult to initiate treatment [11]. When parents communicated
openly and warmly with the adolescent about the dangers of substance use and treatment options, there was
an increased odds of substance abuse treatment being sought out and completed [11]. Self-help groups and
outpatient rehabilitations were the most commonly used treatment settings [11]. Adolescents aged 12–13 years
used any treatment type (i.e. medical, self-help groups, etc.) less often than 16–17-year-olds, fewer Blacks used
medical treatment and self-help groups than Whites [11]. Blacks and Hispanics in non-metropolitan areas face
additional treatment barriers and have reported being socially isolated and not wanting to seek treatment help
[11]. Drug use differs between adolescent and adult Blacks and efforts to reduce drug use during the adolescent
phase is critical [11].

Overall, roughly 36% of adolescents, aged 12–17 years, reported use of non-medical opioids, experienced
symptoms consistent with OUD, but did not report a need for treatment [11]. Among those with an OUD, 83%
of adolescents elicited symptoms consistent with opioid dependence, and 84% of those with abuse patterns,
did not receive substance abuse treatment; while 89% with dependence and 95% with abuse reported no recog-
nizable need for treatment [11]. Even when adolescents meet criteria for treatment, and treatment is available,
they are unlikely to use them due to concerns of stigma, not perceiving having a problem, ease of availability
of opioids, and the perception that opioids are safer than illicit drugs [11]. Overall, 34% of adolescent users re-
ported not being ready to stop using, 22% did not want others to find out about their use, and 22% thought that
receiving treatment might cause their neighbors to have negative opinions of them [11]. In regard to treatment,
21% said they could handle the problem on their own without treatment, 18% said they did not need treatment
and 10% cited a cost concern or that their insurance did not cover treatment [11]. Among adolescents with an
OUD, 8% did not know where to receive treatment, 8% did not think treatment would help and 8% said they
did not have the time to seek out treatment [11].

From 1999 to 2010 deaths attributed to opioid overdose rose six-fold in adolescents aged 15–24 years [12].
Emergency department visits and hospitalizations for opioid misuse have also risen over the past two decades
[13]. Gaither et al. [13] conducted a retrospective analysis, every 3 years starting in 1997, from the Kids’ Inpatient
Database (KID) on those aged 1–19 years, from 1997 to 2012. From 1997 to 2012 a total of 13,052 adolescents,
aged 1–19 years, were hospitalized for prescription opioid poisonings; those aged 15–19 years accounted for
the largest proportion of poisonings [13]. In 1997 males accounted for 34.7% of the hospitalizations, while in
2012, they accounted for 47.4% [13]. Adolescents who misused opioids were found to be predominantly White,
and covered by private insurance; however, the proportion insured by Medicaid increased from 24.1% in 1997
to 44.0% in 2012 [13]. During the study, 176 children died during their hospitalization [13].

From 1997 to 2012 the number of annual hospitalizations due to opioid poisonings, per 100,000 children,
aged 15–19 years increased 176% [13]. Children aged 10–14 years had a 37% increase in the incidence of opioid
poisoning due to a self-inflicted injury or suicide [13]. This trend was more remarkable in those aged 15–19 years
with opioid poisonings, attributed to self-injury or suicide, with a 140% increase [13]. Overall, hospitalizations
due to opioid poisonings among those aged 1–19 years increased almost 2-fold from 1997 to 2012, with the
second largest increase among those aged 15–19 years [13]. Medicaid coverage of those with opioid poisonings
increased from 24.1% to 44% and calls to poison control centers markedly increased [13].

From 2011 to 2013 the number of opioid prescriptions dispensed slightly decreased, as did the number of
hospitalizations for prescription opioid poisonings from 2009 to 2012 [13]. Ten percent of high school seniors
reported using prescription opioids for nonmedical purposes, however, for roughly 40% of those students, they
had their own opioid prescription [13]. From 2005 to 2007, opioids were prescribed to adolescents complaining
of back pain at a prevalence rate of 22% [13]. From 2007 to 2008, nearly 50% of those aged 13–17 years who
presented with a compliant of headache received opiate prescriptions during their 2-year follow-up [13].

In a study by Vaughn et al. [12] risk of opioid abuse classes were established through data from the 2008
NSDUH. Computer-assisted interviews were used by the NSDUH to collect information from adolescents aged
12–17 years on nonmedical opioid use [12]. A total of four classes were identified through the NSDUH; a low-
risk class (33.7%), a high delinquency/low substance use class (17.8%), a high substance use/low delinquency
class (34.2%) and a high overall risk class (14.3%); the low-risk class is the reference category [12]. Males were
3 times more likely to fall into the high-risk and high substance use/low delinquency class than females [12].
African Americans were more likely to fall into the high delinquent/low substance use class than Whites [12].
Adolescents from lower income households were more likely to fall into the risk classes [12]. A history of in-
carceration increased the odds of falling into all three risk classes, anxiety had an effect in predicting whether
someone would fall into the high-risk class, and family involvement and supervision reduced the likelihood

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DE GRUYTER Spencer and Weathers

across all risk classes when compared to the low-risk group [12]. In addition, adolescents who participated in
a violence or drug prevention program had greater odds of falling into the high delinquency/low substance
use and high-risk classes [12].

The male gender, a history of incarceration, anxiety, low family income and a lack of support from parents
are strongly associated with adolescents falling into the high-risk class [12]. About one-third of adolescents
were in the low-risk group because they demonstrated little involvement with substance use and delinquency
[12]. Another third of the adolescents represented those in the high substance use/low delinquency class [12].
The remaining third was spread between the high delinquency/low substance use and overall high-risk class
[12]. Overall, all three risk classes, compared to the low-risk class, had less parental involvement, suggesting
the importance of parental involvement in lowering substance abuse [12].

Among adolescents ages 12–17, opioids were the second most abused substance from 2005 to 2008 [14]. Wu
et al. [14] addressed racial/ethnic differences in substance-related disorders and the prevalence of substance
use among adolescents. Data was obtained from the NSDUH from 2005 to 2008, in which computer-assisted
interviews were conducted with roughly 67,500 individuals aged 12 and older regarding his/her use of alco-
hol and nine drug classes (including opioids) [14]. Approximately one in 12 adolescents self-reported having a
substance abuse disorder [14]. Among those interviewed, Native Americans had the highest prevalence of sub-
stance use and related disorders, and Native Americans, Whites, Hispanics and multiple race/ethnicity were
disproportionately affected by substance abuse disorders [14].

Of the nine drug classes, opioid abuse fell second (to marijuana) at a use rate of 7% [14]. Native Americans
had the highest substance use rate (47.5%), adolescents of multiple race/ethnicity came second (18.1%), and
White adolescents had the third highest abuse rate at 16.2% [15]. Overall opioid use disorders, among all races
and drug use disorders, had a prevalence rate of 1.2% [14]. Native Americans had the highest prevalence of
substance use related disorders at 15%, multiple race/ethnicity at 9.2%, Whites at 9.0%, Hispanics at 7.7%,
African Americans at 5.0%, and Asians or Pacific Islanders at 3.5% [14]. The average number of days per year
using opioids was 39 days [14].

Opioids are the second most commonly abused substance, following marijuana, replacing inhalants (which
used to be more commonly used than opioids) [14]. Opioids are the second most commonly abuse substance
among all race/ethnic groups with Native Americans, Whites, and multiple race/ethnicity showing the highest
rates of abuse [14]. Close to one-tenth of multiple race/ethnicity adolescents self-reported a substance-related
disorder, and approximately one-fourth of opioid users had never used other illicit drugs [14]. Adolescents
generally consider opioids safer than other illicit drugs, and they are easier to obtain (from parents’ medicine
cabinets, family members and friends as primary sources) [14].

Social influence has the greatest impact on substance abuse and misuse [15]. Participants, between the ages
of 13 and 22 years, who were considered healthy and stable in their addiction recovery, were recruited from
two addiction recovery high schools, and given a 20 min questionnaire describing polysubstance abuse, specif-
ically involving opioids [15]. Of the participants 29% were female, 7% Hispanic, 4% Asian, 7% biracial and the
remainder were non-Hispanic Whites; the participants had an average age of 18.2 years [15]. The participants
reported an average age of substance use onset of 11.5 years, with tobacco, alcohol and/or marijuana in some
combination, while opioid use started, on average, at 15 years of age [15].

Half of the study participants indicated their motivation for escalating their substance use was because
their friends were using; secondary motives included curiosity and experimentation [15]. More than 90% of
participants had a family history of substance use, many specifically with a history of opioid use, and all were
polysubstance users in various combinations [15]. Among the participants, 48% reported using at least four
other substances in combination with opioids, and more than half reported that opioid use led to dependence
[15]. Among the participants, 61% obtained access to their first opioids through peers, 16% obtained opioids
by stealing them, 13% reported abusing their own prescriptions, 7% obtained access through family members
and 3% through dealers [15].

Peer substance abuse has been found to be a high predictor of future opioid use [15]. Despite a majority
of participants coming from families with a history of substance use, most participants indicated an increased
exposure to opioids through substance-using peers, which led to a greater likelihood of initiation of use, in-
creased use frequency and greater use duration [15]. Substance use, which begins at younger ages (in this study
the youngest use started at 8 years old), are often because of peer culture to use [15]. Those with polysubstance
use at younger ages were also more likely to increase their use to include opioids [15]. Interventions to target
peer culture is suggested, to reduce the risk of opioid dependence in later years [15].

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