沈绍功教授临床经验汇讲
(这是前100讲，摘自华夏中医论坛，还有101-139讲)
韩学杰博士主讲
AA01
一，中医的优势和特色
一、整体观念:整体观念是关于事物和现象的完整性、统一性和关联性的认识。中医学把人体内脏和体表各部的组织、器官看成是一个有机的整体，同时认为四时气候、地土方宜、周围环境等因素对人体的生理病理有不同程度的影响，既强调人体内部的统一性，又重视机体与外界环境的统一性，这就是中医整体观念的主要内容。
中医和西医的区别是什么,中医是看人、西医是看病，中医是看有病的人，西医是看有人的病。比如感冒:老年、小孩、男人、女人、经期、非经期治疗手段不一样。咽喉发炎，和长期的咽炎不一样，刚发炎，正气盛，邪毒盛;常发炎，长久不好，正气虚;老年人发炎，气不足用补药，所以要用整体观念。再如:头痛，你要问是什么性质的头痛,生气后头痛，肝气郁结;劳累和熬夜后头痛，肾气不足;有的经期头痛，气血虚;有的吃肉饮食过后头痛，痰湿重;你看很简单的一个东西，你要问清楚。所以有些是必须要问的，有些可能是一带而过。西医看病，就是说你得了糖尿病，你得了高血压病，所以它病是一样的，治疗方案是一样的，中医绝对不一样，它要看得病的人。你瘦子得了病，从脾胃上给你治疗;你这个胖子生病从内分泌给你调;你这个爱吃肉爱喝酒的人得了糖尿病，我从利湿上给你调;有人老口渴，消渴，那我把你这个消渴消除了，糖尿病也好了。所以就是说针对病人的时候，一个是病要看，另外看他病由什么而生，这样的话，你给他用药的时候，你给他调脾胃，他可能就好，你咳嗽呢，你可能调肾他也好，所以这个整体很重要。中医的东西也许涉及到性格，我刚才说在那哪种情况下头痛的性质大，要弄清那种性质的头痛很重要。一患者到协和医院就诊看头痛，协和医院给开天麻丸，养血止痛片，并嘱已不是痛的厉害不要吃止痛药，不辩证不对症效果不好。
二、恒动观念:运动是物质的存在形式及其固有属性。世界上的各种现象都是物质运动的表现形式。运动是绝对的、永恒的，静止则是相对的、暂时的和局部的。简单说人是变化的病也是变化的。如感冒在春季、夏季、暑季，秋季、冬季、还是产后小儿是不一样的。刚感冒时的症状吃两服药后变化也是不一样的，所以治感冒开的药不要太长，尤其是小儿一两付就变化，大人最多开两三付。感冒尤其高烧，患扁桃体炎、支气管炎、肺炎，一般的发烧三副汤药可退烧，有合并症时一般5天也可退，所以中医治疗感冒只要对症比西医快得多。这是恒动病情和肌体都有变化，所以方子不能死守，但有些慢性病方子可以开的长一些，如高血压病、高血脂症。
三、开放观:学中医的人要接受各类的思想和多种多样的知识，要接受现代的医学知识，对各种化验检查要能看懂，提高自己的视诊范围。
现在医学提出一个观念叫亚健康。什么叫亚健康,亚健康就是不健康，就是病人。治疗urban area 2.5.2 Yibin city in Yibin city, according to resource and environment characteristics Urban population and urban spatial distribution, spatial distribution of industries, major infrastructure Corridor layout, combined with the future development trend of synthetic judgments, planning, urban spatial structure of urban system can be summarized as: 'a pole along the two axes'. 'A' refers to the metropolitan area along the Yangtze River, is the core area of the development of the city. Plans to build for the Yangtze River economic belt on the pillar, advancing along the ... Guanghe River, Yiliang, prestige of the external cohesion of zhaotong, Yunnan, internal connecting Yibin city to the North. The Sichuan-Yunnan-Guizhou border area of Yibin, in the city of zhaotong, liupanshui three, zhaotong city, the most populous and most extensive regions, the most economically backward, to the North in Wumeng mountain area of yanjin, shuifu, suijiang counties radiation power is relatively weak. Yibin city and infrastructure in such areas should be strengthened and docking, extending southward to public services, promote the development of mineral resources in Northeast Yunnan, expand our economic hinterland, driving synchronous lifting in Sichuan-Yunnan-Guizhou border area. This urban axis with mineral resource advantages, focus on the development of advanced technology, comprehensive utilization of resources of higher energy, new building materials, chemical industry, developing new energy and mining towns. Urban space organization-in gongxian County, Gao, junlian County Center for area organizations, improve, Gao, Gong, junlian County comprehensive services, and promoting regional economic development and population growth of the agglomeration. Along the main traffic arteries to implement 'point-axis development' mode key repeatedly, Shahe town, Xiao Zhen, Luo table Zhen, Luo town, love Mu Zhen and other towns as district development focuses on cities and towns, promote the development of district
亚健康就是运用中医的治未病思想，做到未病先防，即病防变，病后防复。现在预防心血管病，长期服用阿斯匹林，有的病人吃出胃溃疡十二指肠溃疡，所以给病人治疗时一定要中和，防治药物给人带来的不良反应，防止药物的不良反应给人致病，临床看到很多因服药不良而造成的种种反应。
四、综合观:就是运用各种治疗手段，综合治疗，提高临床疗效。如有的人服汤药呕吐，可以采用少量多次的服法，也可运用针灸、按摩、足疗等综合治疗提高疗效。学习中医的人要开放脑筋，吸收外界的精华和长处，来提高自己的水平。
二中医临症的指导思想
一、中西医要链接。
在临床时中医和西医一定要链接，要接轨。如中医的胸痹，病人听不懂，就可以直接叫心肌缺血或叫冠心病，可以运用现代医学名称;再如尿频、尿急、尿痛，西医叫泌尿道感染就不要用中医的淋证了，所以要用西医的病名解释中医的病症。
二、传统和现代要链接。
如传统的诊脉，可以大致看出哪个脏腑有问题，有火有热分得开来，虚证和实证能分得开。但要看血色素是多少，血压多高，骨髓象怎样，所以要和现代医学结合起来。
临床治疗病人千万不要说一定能治好，万一治不好没法向病人解释，尤其是肿瘤病人，有时早期就表现一个感冒、咳嗽、胃痛，发现不了，等发现时患者会说你把我病给耽误了，所以说话要留有余地。
一脑梗塞的患者来院时比较躁动不安，大家记住了，越是脑出血的病人、脑梗塞的病人躁动效果都不好，病情还在发展，尤其是脑出血或突然性的外伤躁动一般预后都不好，脑血管的病人一定要少用镇静剂，。有时会突然昏迷脑出血而死亡。所以西医的知识中医一定要了解。
三、中医是线性和非线性的结合。
线性就是直接的，比如胃痛给654-2止痛就是线性的。但中医胃痛单给止痛行吗,是不行的，是不能治好病的。腹痛的患者一定要检查，有没有胃穿孔，有没有坏死性胰腺炎，所以不能单纯止痛，掩盖病情。
例:一患者，男，27岁，长期有胃炎，一天后吃完饭后胃痛患者自己吃香砂养胃丸，一会胃胀，一小时后发烧，在航天医院检查是胃穿孔、腹膜炎、麻痹性肠梗阻。航天医院治疗无效转到东直门医院。检查一看大量的腹腔积液，炎性包快，打消炎药无效，患者不能下床。十一前找我治疗，查腹胀、痛，舌苔腻。给于三仁汤，温胆汤，吃完后舌苔腻消失，腹痛、胀皆减轻。西医消炎没有解决根本问题，患者的湿气没有解决。所以中医是一种非线性的治疗。患者腹膜积液很大，用了葶苈子30g，白花蛇舌草30g，一周后腹水消失。
四、实体本体论和关器本体论。
西医讲胃就是消化，脾就是造血器官。中医认为脾胃是一个系统，脾主运化水谷，升清降浊，脾统血。尤其打空嗝的病人，饭后病人打嗝，胃气不降，腹胀，不能吃饭，有的人气
-Yunnan-ing synchronous lifting in Sichuan, drivouthward to public services, promote the development of mineral resources in Northeast Yunnan, expand our economic hinterlanddiation power is relatively weak. Yibin city and infrastructure in such areas should be strengthened and docking, extending sregions, the most economically backward, to the North in Wumeng mountain area of yanjin, shuifu, suijiang counties raGuizhou border area of Yibin, in the city of zhaotong, liupanshui three, zhaotong city, the most populous and most extensive -Yunnan-ichuanThe S . Guanghe River, Yiliang, prestige of the external cohesion of zhaotong, Yunnan, internal connecting Yibin city to the North.area of the development of the city. Plans to build for the Yangtze River economic belt on the pillar, advancing along the ..core system can be summarized as: 'a pole along the two axes'. 'A' refers to the metropolitan area along the Yangtze River, is therridor layout, combined with the future development trend of synthetic judgments, planning, urban spatial structure of urban patial distribution, spatial distribution of industries, major infrastructure Courban area 2.5.2 Yibin city in Yibin city, according to resource and environment characteristics Urban population and urban s2romote the development of districtict development focuses on cities and towns, paxis development' mode key repeatedly, Shahe town, Xiao Zhen, Luo table Zhen, Luo town, love Mu Zhen and other towns as distr-ion growth of the agglomeration. Along the main traffic arteries to implement 'pointces, and promoting regional economic development and populatin gongxian County, Gao, junlian County Center for area organizations, improve, Gao, Gong, junlian County comprehensive servi-stry, developing new energy and mining towns. Urban space organizationehensive utilization of resources of higher energy, new building materials, chemical induGuizhou border area. This urban axis with mineral resource advantages, focus on the development of advanced technology, compr
不排肚子胀，通腹既能减轻症状。对于打空嗝的人，一看便知是从气上得的，需疏肝理气才会有效。过度的紧张焦虑易得溃疡病，要柔肝调胃才能治好。中医大夫要知道实体的脾胃肝胆是什么样的，还要知道他们之间的相互关系。所以冠心病有从五脏论治，有从痰论治，有从肾论治。有的冠心病喝酒，睡眠不好，劳累，情绪不好，单从上述方法论治效果也不好。有的人治疗冠心病以补为主。如果患者舌苔腻补法无效，越吃舌苔越粘，越吃越难受。
五、混沌无序与清晰有序。
什么叫混沌无序,有人说中医叫糊里糊涂看病，能看好就算。西医明明白白治死。西医治病，诊断清楚，治疗明确，有时有很大的毒副作用。在非典流行时，西医大量使用激素，造成肺纤维化，股骨头坏死等不良后果，给病人带来终身痛苦和遗憾，同样的病，在广州用中药治疗，上述反应小，效果良好，说明中医治疗非典有一定的优势。今年北京流行H1N1流感，用中药治疗，效果很好。目前在医学上有很多慢性病，西医治疗无能为力，如高血压、糖尿病、冠心病，这些病可以发挥中医的优势，使高血压、糖尿病和冠心病的病人不必终身服药，而且有很多患者可以治愈。
有一个小孩，12岁，得了一个怪病，青春期面部骨骼发育不完全，骨骼增生，颧骨突出，到协和医院就诊，说这种病很难见到，到青春期可以停止增生，没有特殊的治疗办法，西医可手术把增生的颧骨磨下去，患者没有同意求中医治疗。中医对异常的增生可以归纳为痰核、结节。病机往往为气滞、血瘀、痰凝。如甲状腺结节、乳腺结节、肝囊肿、肾囊肿，根据上述中医理论治疗。这个小孩，老师给予健脾胃，化痰。用犀黄丸加龙胆粉、羚羊角粉治疗一段时间后，颧骨增生停止。
老师亲近的孩子得一血管瘤，激光治疗后遗留色素沉着斑，老师用调脾胃升清阳的办法治疗，2个月后色素沉着斑几乎消失。
中医治病，脑子一定要灵活，不能固守，治疗一个病时一定要考虑和此病相关的病。大家都知道，目前治疗肿瘤，用大量的激素，放疗、化疗，肿瘤有时消失了，可病人不能耐受放化疗也死亡了，西医治疗肿瘤，瘤子消了，人也死了。中医治疗肿瘤，有时肿瘤不消失，甚至有的还可以增长，可是经过中医治疗，患者可以长期的带瘤生存，甚至完全治愈，生活质量良好。
一乳腺癌的患者，乳房坚硬如石，乳房扩大切除术后，放化疗治疗，转氨酶升高到1000U,肝区疼痛难以忍受，后停用放化疗，有中药治疗，至今已有四年，患者生活良好，乳腺癌没有复发。肿瘤的病人治疗时一定要兼顾其它的脏器，不能伤胃、不能伤肝。治疗类风湿关节炎、痛风的病人用雷公藤治疗，效果很好，可往往引起肝肾的损害，引起患者的死亡。甲状腺增生，黄药子治疗效果很好，治疗后有时引起淋巴细胞、白细胞的降低和肝肾的刺激，所以此药不宜应用，要用也要中病即止。给病人治疗，要时时考虑病人的经济负担。如一患者，患尿崩症，每天喝40斤水，不喝水睡不着觉，可是一喝水就尿，白天晚上的折腾。一医生开的全是贵重药，人参、西洋参、川红花等名贵药每付汤药400多元，给患者增加了不必要的经济负担，而且治疗效果不好，后来到老师看病，每付汤药不过十几块钱，所以做医生医德要好。
-Yunnan-ynchronous lifting in Sichuanving sard to public services, promote the development of mineral resources in Northeast Yunnan, expand our economic hinterland, drion power is relatively weak. Yibin city and infrastructure in such areas should be strengthened and docking, extending southwregions, the most economically backward, to the North in Wumeng mountain area of yanjin, shuifu, suijiang counties radiatiGuizhou border area of Yibin, in the city of zhaotong, liupanshui three, zhaotong city, the most populous and most extensive -Yunnan-nSichuanghe River, Yiliang, prestige of the external cohesion of zhaotong, Yunnan, internal connecting Yibin city to the North. The of the development of the city. Plans to build for the Yangtze River economic belt on the pillar, advancing along the ... Guaarea m can be summarized as: 'a pole along the two axes'. 'A' refers to the metropolitan area along the Yangtze River, is the corer layout, combined with the future development trend of synthetic judgments, planning, urban spatial structure of urban systepatial distribution, spatial distribution of industries, major infrastructure Corridourban area 2.5.2 Yibin city in Yibin city, according to resource and environment characteristics Urban population and urban s3e the development of districtict development focuses on cities and towns, promotaxis development' mode key repeatedly, Shahe town, Xiao Zhen, Luo table Zhen, Luo town, love Mu Zhen and other towns as distr-rowth of the agglomeration. Along the main traffic arteries to implement 'pointces, and promoting regional economic development and population gin gongxian County, Gao, junlian County Center for area organizations, improve, Gao, Gong, junlian County comprehensive servi-developing new energy and mining towns. Urban space organization ehensive utilization of resources of higher energy, new building materials, chemical industry,Guizhou border area. This urban axis with mineral resource advantages, focus on the development of advanced technology, compr
AA02
证候要素
1、靶位的提取。所谓靶位就是治疗的方位，也就是中医处方的治疗方向，一张中医处方，针对主要病机进行治疗，同时又要治疗主要兼症，做到主证清晰，兼症明确，有效提取治疗靶点。
如高血压病，过去的治疗一般都会想到肝阳上亢，阴虚火旺。现代临床除了能看到肝阳上亢、阴虚火旺外，常常会见到阴阳两虚，肾阴不足，痰湿阻络，中气不足等类型。所以靶位的提取很关键，靶位提取错了整个治疗思路就全错了。有些病人开始服中药效果很好，时间久了之后，效果不好了，这时就要坚持效不更法。一般两个原因，一个是病人耐药，一个是病人的靶点发生了变化。如原先的高血压患者头晕减轻，此时又出现了心慌、遗尿等症状，这时就要同时兼顾靶点，靶点变了，药方也要变才能收到理想的效果。现代人生活压力大，工作竞争激烈，社交复杂，想得比较多，这时就要多观察，临床效果的好坏在于，能不能定准位，找准靶点，辩证是否精确。
高血压的治疗，可能有什么样的症状,是头痛、眩晕、耳鸣、还是眼花,这个病有什么样的征候,有的可能有动脉硬化;有的可能有高血压脑病;有的可能伴有骨质增生跟骨痛;有的有高血压的肾损害;有的有高血压引起的心脏损害;要找出规律，精确辩证。有的大夫看高血压有这么多的类型，摸不清用什么方子。其实很简单，一看患者的舌苔腻还是不腻,舌苔腻的要退舌苔，先泻实后补虚。二看患者的胃口怎样，不能吃的要健脾胃，脾胃一开临床才会有效。
2、病、证与症的关系。
“证”是中医学特有的概念，包括证名、证候，证名是对病变所处一定阶段的病因病性、病位等所作的概括;证候是该证的特定临床表现。“症”是指病人主观能感觉到的单个症状。“征”是指被客观发现的体征。“病”代表该具体疾病全过程的特点和规律。
如有的高血压患者，同时伴有糖尿病，高血脂证，心脏病，肾病，失眠这么多的病和症，你说怎么治,急则治其标。吃饭、睡觉、大小便最重要。有些患者长期失眠，长期患有慢性病，只要对生活还有兴趣，只要对生存还有希望就可以治疗。
当医生一定要做到心中有数，什么样的病可治，什么样的病不可治。不可治的病人是亲近朋友也得给治，当大夫一定要学会暗示疗法，给病人以生存的希望，即使是奄奄一息，也要鼓励病人。有些危重病人我们治不好就不要显能，让有条件的医院去治，以下两个例子可以说明问题。
例一:有一扩张型心肌病心衰，住院时尚能控制病情，出院一星期就心衰，尿少浮肿。年龄70多岁，请老师会诊老师没去。为什么没去呢,年龄大了本身的身体已经衰竭，再者西医已经治了这么长的时间了，治也不会好到哪去，病人已经到了疾病的晚期，如果出现大小便闭，很快就会死亡。
例二:有一小孩发烧，到人民医院会诊，诊断为白血病，体温39-40度，已经烧了一个月，心率快140次每分钟，有出血，老师给开了7付药，服药途中突然大出血死亡。
-Yunnan-ing synchronous lifting in Sichuan, drivouthward to public services, promote the development of mineral resources in Northeast Yunnan, expand our economic hinterlanddiation power is relatively weak. Yibin city and infrastructure in such areas should be strengthened and docking, extending sregions, the most economically backward, to the North in Wumeng mountain area of yanjin, shuifu, suijiang counties raGuizhou border area of Yibin, in the city of zhaotong, liupanshui three, zhaotong city, the most populous and most extensive -Yunnan-ichuanThe S . Guanghe River, Yiliang, prestige of the external cohesion of zhaotong, Yunnan, internal connecting Yibin city to the North.area of the development of the city. Plans to build for the Yangtze River economic belt on the pillar, advancing along the ..core system can be summarized as: 'a pole along the two axes'. 'A' refers to the metropolitan area along the Yangtze River, is therridor layout, combined with the future development trend of synthetic judgments, planning, urban spatial structure of urban patial distribution, spatial distribution of industries, major infrastructure Courban area 2.5.2 Yibin city in Yibin city, according to resource and environment characteristics Urban population and urban s4romote the development of districtict development focuses on cities and towns, paxis development' mode key repeatedly, Shahe town, Xiao Zhen, Luo table Zhen, Luo town, love Mu Zhen and other towns as distr-ion growth of the agglomeration. Along the main traffic arteries to implement 'pointces, and promoting regional economic development and populatin gongxian County, Gao, junlian County Center for area organizations, improve, Gao, Gong, junlian County comprehensive servi-stry, developing new energy and mining towns. Urban space organizationehensive utilization of resources of higher energy, new building materials, chemical induGuizhou border area. This urban axis with mineral resource advantages, focus on the development of advanced technology, compr
3、方，病，证的关系。
病是由若干个证组成，方子是反映某一具体的证的表现形式和治疗手段。方子是根据证候，用方时一定要依据证候。如用枸杞地黄丸、知柏地黄丸，患者服完后看病人还有什么症状，还有什么治疗不到的地方，根据具体病情加减用药。杞菊地黄补肝肾，假设病人还有头昏，那就需要加天麻，大便干燥的加草决明，以一个方子为主，随症加减，有多少个点，就加相应的药，提高临床疗效。
4、病机规律。
一般疾病刚发病时往往是邪气盛正气不虚。时间长了，疾病就会向虚症发展，治疗也就相对困难。服药也是一样，刚开始时效果很好，随着服药的时间延长，效果就相对差了。古语说嘛:“病来如山倒，病去如抽丝”，就是这个道理。人的躯体和生命是一次性的，40岁以上的人往往又是慢性病居多，医生有时能帮助患者做到的是减轻一些痛苦，症状改善一些。有些病和患者的不良嗜好有直接的关系，如酒精肝的患者，医生不让你喝酒，可你天天喝酒，医生不让你生气，可你看什么都生气;心肌梗塞的病人为什么会猝死，往往和生气有直接的关系;脑出血的病人往往也一样。所以中医证候的摘取有一个层次，一定要分隔开来。这就要看他的现象，表现是什么,如果头痛头昏，手足颤抖，中医叫肝风内动，经脉不通。发烧也是一样，有早晨发烧、中午发烧、晚上发烧、饭后发烧，这些不同的发烧背后隐藏的病机是不同的。是气虚、血虚、阴虚、阳虚、湿热、痰湿、淤血等内伤发热:还是风寒、风热、风湿、暑湿，温燥、凉燥等外感发热。中医治疗发烧证型多，效果好，副作用小比西医有明显的优势。西医治疗感冒发烧，用退烧药，有时造成大汗淋漓，烧退后病人很虚弱。再如:食物中毒的患者，刚开始是吐泻不停，先不要止吐止泻，过早的止吐止泻容易留邪，等吐泻完后根据病情给患者服汤药或者输液治疗。黄连素，藿香正气水对食物中毒有效，痢疾的脓血便不止，可口服庆大霉素水，可很快止泻。
证候要素的特证
1、内实外虚。
是里有实邪，外有虚证的一组临床表现。
如食物中毒。有腹痛腹泻的同时，又有出汗、四肢厥冷、头晕等虚证的临床表现。这时的虚证就不要补，越补越呆，影响脾胃的运化，要清胃肠的湿热。同样感冒发热，在发热的同时又伴有怕冷，甚至寒战，这时就要分清风寒和风热。一般通过四点可以分清，一是风寒的患者发热轻恶寒重、怕风，得衣被而症状不减，风热的患者发热重，恶寒轻或者怕热;风寒的患者身痛、体痛、头痛，风热的患者咽喉痛或者舌边尖红;风寒的患者舌苔薄白，风热的患者舌苔薄黄;风寒的患者脉浮紧，风热的患者脉浮数。如果病人怕冷，寒证为主，不要用清热解毒药，要散寒却风，否则寒证未调引邪入内。
2、动态时空。
病情是在不断的变化的，证候和症状也是不断的变化的。如感冒的患者，起先是风寒感冒，如果误治或失治，外邪郁而化热，或转变入里;有些小儿感冒，常常夹有食滞;有些病原先是实证，久治不愈之后也可转变为虚证。
-Yunnan-ynchronous lifting in Sichuanving sard to public services, promote the development of mineral resources in Northeast Yunnan, expand our economic hinterland, drion power is relatively weak. Yibin city and infrastructure in such areas should be strengthened and docking, extending southwregions, the most economically backward, to the North in Wumeng mountain area of yanjin, shuifu, suijiang counties radiatiGuizhou border area of Yibin, in the city of zhaotong, liupanshui three, zhaotong city, the most populous and most extensive -Yunnan-nSichuanghe River, Yiliang, prestige of the external cohesion of zhaotong, Yunnan, internal connecting Yibin city to the North. The of the development of the city. Plans to build for the Yangtze River economic belt on the pillar, advancing along the ... Guaarea m can be summarized as: 'a pole along the two axes'. 'A' refers to the metropolitan area along the Yangtze River, is the corer layout, combined with the future development trend of synthetic judgments, planning, urban spatial structure of urban systepatial distribution, spatial distribution of industries, major infrastructure Corridourban area 2.5.2 Yibin city in Yibin city, according to resource and environment characteristics Urban population and urban s5e the development of districtict development focuses on cities and towns, promotaxis development' mode key repeatedly, Shahe town, Xiao Zhen, Luo table Zhen, Luo town, love Mu Zhen and other towns as distr-rowth of the agglomeration. Along the main traffic arteries to implement 'pointces, and promoting regional economic development and population gin gongxian County, Gao, junlian County Center for area organizations, improve, Gao, Gong, junlian County comprehensive servi-developing new energy and mining towns. Urban space organization ehensive utilization of resources of higher energy, new building materials, chemical industry,Guizhou border area. This urban axis with mineral resource advantages, focus on the development of advanced technology, compr
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