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CHEMPAK and the Maine Pharmacy Cache. Maine CDC Office of Public Health Emergency Preparedness (OPHEP) & The Northern New England Poison Center. Dan Lambert, MBA, RPh, EMT-I Consultant Pharmacist Karen Simone, PharmD, DABAT Director Tamas Peredy, MD Medical Director.

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CHEMPAK and the Maine Pharmacy Cache

Maine CDCOffice of Public Health Emergency Preparedness (OPHEP)

&

The Northern New England Poison Center


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Dan Lambert, MBA, RPh, EMT-IConsultant PharmacistKaren Simone, PharmD, DABATDirectorTamas Peredy, MDMedical Director

Northern New England Poison Center


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Antidotes Flow

Maine Pharmaceutical Cache

CMMC, EMMC, MMC, (TAMC)

All other ME Hospitals

Chempacks

Calais, Cary, CMMC, EMMC, Franklin, MMCx2, ME Gen Aug, MDI, SMMC

Strategic National Stockpile

Regional

1st

2nd

3rd


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Antidotes Content

Maine Pharmaceutical Cache

CMMC, EMMC, MMC, TAMC: BAL, DMPS, cipro, doxy, EDTA, hydoxocobalamin, KI, Prussian blue

Others: atropine/2-Pam, Ca gluconate, fomepizole

CHEMPACKs

Calais, Cary, CMMC, EMMC, Franklin, MMCx2,

ME Gen Aug, MDI, SMMC: atropine/2-Pam

Strategic National Stockpile

Antidotes, other medicine, medical supplies

Min-hrs

Hrs

<12 hrs??


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Maine Pharmaceutical Cache

  • Distributed for the Maine CDC by the Poison Center

    • Larger supplies at CMMC, EMMC, MMC, & TAMC

    • Smaller quantities at other hospitals

  • Antidotes (some only at key 4 hospitals):

    • Atropine/2-Pam (pralidoxime)

    • BAL, DMPS, EDTA, Prussian blue

    • Ciprofoxacin, doxycycline

    • Fomepizole

    • Hydoxocobalamin

    • KI

  • For first 24 – 48 hours

    • Until CHEMPACK or federal supplies are available


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Maine Pharmaceutical Cache Deployment

EMS, ED or other requests deployment

Call Northern New England Poison Center (NNEPC)

1-800-222-1222

NNEPC will assist with:

Drug indications and dosing

Locating and transporting supplies

NNEPC notifies Maine CDC

Maine CDC contacts Maine Emergency Management Agency (MEMA)

MEMA collaborates & coordinates on asset use


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CHEMPACK

The CDC established CHEMPACK, which is the forward placement of a sustainable resource of Nerve Agent (NA) antidotes throughout the United States

Deployment and maintenance of CHEMPACK in Maine is the responsibility of the Maine CDC-Office of Public Health Emergency Preparedness.


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CHEMPACK

  • Nerve Agent (NA) Antidotes

  • Stored within States

    • Prior to an incident

  • Maine Locations: Calais, Cary, CMMC, EMMC, Franklin, MMCx2, ME Gen Aug, MDI,& SMMC


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CHEMPAK (EMS & Hospital Containers)

  • CHEMPACK - EMSContainers:

    • For emergency responders at the scene

    • More single-use auto-injectors

    • Some pediatric

  • CHEMPACK - HospitalContainers:

    • For hospital use

    • More multiuse vials

  • Both:

    • Will treat 1,000 casualties

      • 30% mild exposures

      • 40% moderate exposures

      • 30% severe exposures


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CHEMPACK Supplies

Type:

Needles (18-gauge, 1 1/2- and 5/8-inch, )

Syringes (5ml, 20ml)

Alcohol wipes

How packaged:

1 dose/small zip-lock bag

10 doses/large zip-lock bag

Instructions on each zip-lock bag:

Drug form and concentration

Route of administration

Dosing instructions by age and severity


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Chempack Deployment

EMS, ED or other requests deployment

Call Northern New England Poison Center (NNEPC)

1-800-222-1222

Move CHEMPACK and supplies to ED or loading dock

May remove drugs boxes from the CHEMPACK container to transport

US Centers for Disease Control (CDC) in Atlanta, GA notification

Automatic when open container

NNEPC notifies Maine CDC

Maine CDC contacts Maine Emergency Management Agency (MEMA)

MEMA collaborates & coordinates on asset use


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Strategic National Stockpile

  • 1999: Charge to establish a national stockpile

    • Congressional charge to:

      • Department of Health and Human Services (DHHS) and

      • Centers for Disease Control and Prevention (CDC)

    • Called:

      • The National Pharmaceutical Stockpile (NPS)

  • 2003: The NPS becomes the Strategic National Stockpile (SNS).

    • Large quantities of essential medical materiel

    • For states and local public health agencies

    • During an emergency


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A single “push package” weighs 94,424 pounds and fills either one wide-body aircraft or seven tractor trailers.


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SNS Deployment either one wide-body aircraft or seven tractor trailers.

  • Maine CDC asks governor to request SNS deployment.

  • Partial or complete Push Packages arrive within twelve (12) hours of the federal decision to deploy.

  • Push Package contents are constantly updated but contain in general:

    • Antibiotics - IV administration supplies

    • Nerve agent antidotes - Airway maintenance supplies

    • Antitoxins - Medical/surge items.

    • Life-support medications

  • Technical Advisory Response Unit (TARU) is sent.

    • TARU staff coordinate with state and local officials.

    • SNS assets are efficiently received and distributed.


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Vendor Managed Inventory either one wide-body aircraft or seven tractor trailers.

  • Additional supplies

    • Pharmaceuticals and/or medical

    • After 12-hour push packages (if needed)

    • Within 24 to 36 hours

  • First option

    • If 12-hour turnaround not needed

    • If need is specific to certain known items

OR


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Other Supplies either one wide-body aircraft or seven tractor trailers.

  • US Postal service:

    • Ciprofloxacin and doxycycline

    • At MMC and EMMC

  • Maine EMS:

    • Atropine/2-PAM autoinjectors

    • In ambulances

      • Training requirements


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Antidotes either one wide-body aircraft or seven tractor trailers.

  • CHEMPACK

    • Nerve agent antidotes

  • Maine Pharmaceutical Cache

    • Nerve agent antidotes

    • Chelating agents (heavy metals/radiation)

    • Antibiotics

    • Toxic alcohol antidote

    • Cyanide antidote

    • Radiation (power plant-related)


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Nerve Agents either one wide-body aircraft or seven tractor trailers.

Antidotes in:

CHEMPACK

Maine Pharmaceutical Cache

Strategic National Stockpile


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Nerve Agents Pharmacology either one wide-body aircraft or seven tractor trailers.


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Effects of Nerve Agents either one wide-body aircraft or seven tractor trailers.

  • Muscarinic (Atropine works)

    • Smooth muscles

    • Exocrine glands

  • Nicotinic (Atropine ineffective, 2-PAM works)

    • Skeletal muscles

    • Ganglia (Sympathetic/Parasympathetic)

  • Central Nervous System (Diazepam works)


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M either one wide-body aircraft or seven tractor trailers.uscarinic Effects

Increased secretions

  • Saliva

  • Tears

  • Runny nose

  • Secretions in airways

  • Secretions in gastrointestinal tract

  • Sweating

    Smooth muscle contraction

  • Eyes: miosis (Can use Lidocaine 2%)

  • Airways: bronchoconstriction (shortness of breath)

  • Gastrointestinal: hyperactivity (nausea, vomiting, and diarrhea)


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Nicotinic Effects either one wide-body aircraft or seven tractor trailers.

  • Skeletal muscles

    • Fasciculations

    • Twitching

    • Weakness

    • Flaccid paralysis

  • Other (ganglionic)

    • Tachycardia

    • Hypertension


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Other Signs & Symptoms either one wide-body aircraft or seven tractor trailers.

  • Cardiovascular

    • Bradycardia (muscarinic, late nicotinic)

    • Tachycardia (nicotinic)

    • Heart block, ventricular arrhythmias

  • Central Nervous System

    • Loss of consciousness

    • Seizures

    • Apnea


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ATROPINE either one wide-body aircraft or seven tractor trailers.

Antagonize muscarinic effects

Dry secretions

Relax smooth muscles

Give IV,IM,ET

Starting dose 2mg, cumulative dose 20mg (insecticides may require much larger doses – grams or more in severe cases)

PRALIDOXIME Cl (2PAM-Cl)

Remove nerve agent from AChE in absence of aging

1-2 g IV over 15-30min

5 minutes is possible/not ideal

Rapid IV = hypertension

Helps at nicotinic sites

Nerve Agents Treatment

  • DIAZEPAM

  • Treats seizures

    (Other less-understood beneficial effects)


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Mark I Autoinjector DuoDote either one wide-body aircraft or seven tractor trailers.Atropine 2mg, 2-PAM 600mg


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Nerve Agent Treatment-EMS either one wide-body aircraft or seven tractor trailers.

State of Maine (Mark 1 kits = NAAK):

EMTs can only administer to EMTs (self or other EMTs)

Treat yourself first and then others

Escape the Area/ Notify Dispatch

Decontaminate (strip down / H2O)

DO NOT ENTER ONCE SUSPICION EXISTS

IF Symptomatic use the NAAK Kits:

Atropine

2-PAMCl

NAAK = Nerve Agent Antidote Kit

Mark I = a brand name for NAAK


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Chelating Agents either one wide-body aircraft or seven tractor trailers.

Antidotes in:

Maine Pharmaceutical Cache


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Chelation & Heavy Metal Poisoning either one wide-body aircraft or seven tractor trailers.

  • BAL (British anti-Lewisite, dimercaprol):

    • Lewisite gas (systemic toxicity)

  • DMPS (Unithiol):

    • Arsenic, bismuth?, lead, mercury

  • EDTA, calcium disodium & Succimer:

    • Lead (Zinc)

  • Prussian Blue:

    • Poisoning: thallium


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Dimercaprol & DMPS (Unithiol) either one wide-body aircraft or seven tractor trailers.

BAL (British anti-Lewisite) or Dimercaprol:

Developed to treat Lewisite

An arsenic based poison gas

Injection in peanut oil given IM every 4 hours initially

Maine has supply in largest hospitals

DMPS (Unithiol):

Water soluble analog of BAL

Injection initially, then orally

Maine has supply in largest hospitals


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EDTA, calcium disodium either one wide-body aircraft or seven tractor trailers.

  • Lead:

    • Mostly replaced by DMPS, except in severe cases

    • Important not to give BAL 1st in severe overdoses

      • Then should be given together (BAL and EDTA) for early doses

    • Confusion with sodium EDTA can lead to life-threatening hypocalcemia

    • Maine has supply in largest hospitals

  • Other possible uses:

    • Zinc

    • Manganese

    • Certain types of radiation exposure


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Action: either one wide-body aircraft or seven tractor trailers.

Block GI absorption, enterohepatic recirculation

Dose:

Up to 10 g daily for acute thallium poisoning

1 gm with 4oz water p.o. t.i.d.

Duration:

Possibly several days or more

Maine has supply of powder to be used until commercial supplies obtained

Prussian Blue (Ferric hexacyanoferrate)


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Anthrax Threat either one wide-body aircraft or seven tractor trailers.

  • USSR accidental release (1979):

    • Aerosolized anthrax spores

      • From military microbiology lab

      • At least 79 cases ofanthrax and 68 deaths

  • Potential for harm in US:

    • 3,000,000 deaths from 100 kg spores Upwind of Washington, DC

    • Lethality matching or exceeding hydrogen bomb


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Anthrax either one wide-body aircraft or seven tractor trailers.

  • Spore-forming Bacillus anthracis

  • Inhalation, cutaneous & intestinal

  • Not contagious


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Acute Treatment either one wide-body aircraft or seven tractor trailers.

Inhalation or oral exposure:

IV Ciprofloxacin OR Doxycycline

AND

1 or 2 additional IV antimicrobials (rifampin, vancomycin, penicillin, ampicillin, chloramphenicol, imipenem, clindamycin, clarythromycin)

Dermal exposure:

Oral ciprofoxacin OR doxycyclin

Iv as above if: systemic effects, significant edema, swelling of head/neck region

Post-exposure

Oral Ciprofloxacin OR Doxycycline

Anthrax Treatment


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Fomepizole(Antizol®) either one wide-body aircraft or seven tractor trailers.

  • Antidote for:

    • Ethylene glycol (antifreeze)

    • Methanol (windshield wiper fluid)

  • Inhibits alcohol dehydrogenase

    • Prevents metabolism of ethylene glycol and methanol to toxic metabolites


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Cyanide either one wide-body aircraft or seven tractor trailers.


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The Tylenol Crisis either one wide-body aircraft or seven tractor trailers.

  • Chicago, 1982

    • Extra Strength Tylenol

      • Laced with potassium cyanide

    • 8 bottles

    • 7 people died

  • 31 million bottles recalled

    • Worth $100,000 were

    • $100,000 reward offered

      • Has never been claimed


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Availability of Cyanide (sources) either one wide-body aircraft or seven tractor trailers.

  • Laboratory analysis

  • Solvent for gold and silver

    • Mining, electroplating, metallurgy, jewelry and photography

  • Sodium nitroprusside

    • Antihypertensive

  • Products of combustion

    • Fires

    • Exhaust

    • Tobacco smoke

  • Acetonitrile-based products

    • Artificial nail glue remover


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Cyanide either one wide-body aircraft or seven tractor trailers.(chemistry, mechanism and form)

  • Cyanide chemistry/mechanism

    • Carbon atom triple bonded to a nitrogen atom

    • Irreversible inhibitor of cytochrome c oxidase

      • Disrupts ATP energy production in cell mitochondria

        • Cells unable to use oxygen

  • Hydrogen cyanide (HCN)

    • Colorless gas

    • Faint bitter almond -like odor

    • Not all can smell hydrogen cyanide

  • Sodium cyanide and potassium cyanide

    • White powders


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Cyanide Antidote Kit (old) either one wide-body aircraft or seven tractor trailers.

  • Amyl nitrite (for inhalation)

    • Until IV established

    • Limited usefulness

  • Sodium nitrite (for injection)

    • Causes methemoglobinemia (in sub-toxic amounts)

    • Methemoglobin binds cyanide

      • Pulls cyanide away from cytochrome oxidase

        • Cells able to utilize oxygen again

      • Not recommended for those with compromised hemoglobin

        • House fire victims (smoke, carbon monoxide)

  • Sodium thiosulfate (for injection)

    • Sometimes sufficient alone


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Cyanide Antidote Kit (new) either one wide-body aircraft or seven tractor trailers.


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Hydroxocobalamin either one wide-body aircraft or seven tractor trailers.

Hydroxocobalamin = antidote

Cyanocobalamin = B12


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  • Starting dose of CYANOKIT® - 5g either one wide-body aircraft or seven tractor trailers.

    • 2 x 2.5 g vials (adults)

    • IV infusion over 15 minutes

  • 2nd dose of 5 g

    • May given if needed

    • IV infusion

      • over 15 - 120 minutes


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Adverse Effects/Concerns either one wide-body aircraft or seven tractor trailers.

  • Increased blood pressure

  • Nausea

  • Headache

  • Rash

  • Infusion site reactions

  • Color-related:

    • Interference with laboratory tests (dark red color):

      • Clinical chemistry, hematology, coagulation, urine

    • Erythema (red-colored skin)

      • Most subjects receiving a 5 g dose or greater


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Cyanide Clinical Effects either one wide-body aircraft or seven tractor trailers.

Headache, anxiety, agitation, confusion, lethargy

Tachypnea, bradypnea

Seizures, coma

Agonal respirations, cardiovascular collapse

Cyanide Indications

Known or strongly suspected

cyanide poisoning

AND

Life-threatening clinical effects

consistent with cyanide poisoning


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Ionizing Radiation either one wide-body aircraft or seven tractor trailers.

  • Radiation: energy given off by unstable atoms

    • Can be particles or waves

    • Can damage DNA

Best protection (limit exposure): time, distance and shielding


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Ionizing Radiation - Types either one wide-body aircraft or seven tractor trailers.

  • Alpha:

    • Americium, polonium, plutonium, radium, radon, thorium, uranium

    • Use: industry, power plants, smoke detectors, cancer implants

    • Not absorbed through skin/cannot penetrate paper or clothing

      • Inhalation and ingestion concern

  • Beta:

    • Iodine, phosphorus, strontium, tritium

    • Use: medical diagnosis/imaging/treatment, fission product of power plants

    • Can penetrate skin

      • Inhalation and ingestion concern

  • Gamma:

    • Cesium, cobalt, technetium

    • Uses: medical diagnosis/imaging/treatment, industry(measuring), sterilizing food and equipment

    • Can penetrate the skin and damage internal organs


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Radiation Exposures either one wide-body aircraft or seven tractor trailers.

  • Dirty bomb (radiological dispersion device):

    • Dynamite with radioactive particles/pellets

      • Particles are dispersed with the explosion

      • People and places may be contaminated

      • The explosion is more dangerous than the radiation

  • Nuclear bomb (plutonium-239, uranium-235):

    • WWII (Hiroshima, Nagasaki)

    • Vaporization inside the explosion

    • Contamination from dust falling out around the explosion

  • Power plant incident:

    • Uranium and polonium fission produce iodine

    • Chernobyl

    • Cesium, iodine, strontium

    • Acute radiation sickness and cancer

    • Widespread environmental contamination


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Radiation Poisoning either one wide-body aircraft or seven tractor trailers.

  • Prodromal stage (0 - 48 hours):

    • Mild-moderate: GI (nausea, vomiting, abdominal cramps, diarrhea)

    • Severe: confusion, ataxia, diaphoresis, fever, coma, shock, death

  • Latent stage (hours – days):

    • Apparent recovery

  • Manifest illness stage (1 - 60 days):

    • Bone marrow suppression (infection, death possible)

    • Multiple organ system toxicity

  • Recover phase (weeks – months):

    • Hair loss, burns/scars


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Blocking and Mobilizing Agents either one wide-body aircraft or seven tractor trailers.

Aluminum salts (Phosphate prefered)

  • Mylanta/Maalox 2-3x GERD dose

  • Strontium reduced absorption and enhanced elimination

    Urine Alkalinization (+ potassium supplement)

  • 1 L D5W add 3 amps (50 meq each) NaHCO3, give IV 2-3x maintenance

  • Enhanced uranium elimination

    Dilution

  • Isotopic dilution is simple hydration and diuresisto reduce isotope concentration and enhance elimination


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Blocking and Mobilizing Agents either one wide-body aircraft or seven tractor trailers.Potassium Iodide

  • Use in radioactive iodine poisoning

  • Not a chelating agent. Acts to block thyroid deposition of radioactive iodine

  • 90% effective within 1 hour to 40% at 8 hours

  • Dose: 130mg immediately, then 130mg daily for 7 days

  • Maine CDC has prepositioned potassium iodide powder in hospitals to act as an initial supply if other supplies are not available.


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Chelating Agents either one wide-body aircraft or seven tractor trailers.

DTPA Diethylene triamine penta acetic acid

  • Removes 90% soluble plutonium 1hour post exposure

  • Initial dose Ca-DPTA 1g IV/neb (14mg/kg), then Zn-DTPA 1g IV qD x 14-90 days

  • Time sensitive, Teratogenic

  • Need to check trace metal levels

    PRUSSIAN BLUE

  • 3g PO TID x 30 days

  • Insoluble

  • Absorbs Cs-137, Th-201 from gut


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Thank you! either one wide-body aircraft or seven tractor trailers.

Maine CDCOffice of Public Health Emergency Preparedness

&

The Northern New England Poison Center

To receive 1 hour Maine Board of Pharmacy CE credit,

Paste the following link in your web browser and complete the evaluation. A CE certificate will be mailed o you for a score of 70% or more.

http://www.surveymonkey.com/s.aspx?sm=ZVNqYYOh0OyCKb_2bgg3R7vA_3d_3d