33 results found
Mullins E, Lees C, 2021, Responding to a pandemic: UK universities’ research into COVID-19
Naji O, Souter V, Mullins E, et al., 2021, The blind spot: value‐based health care in obstetrics and gynaecology, The Obstetrician & Gynaecologist, ISSN: 1467-2561
Key contentContinuing financial constraints on the UK’s National Health Service means the need for clinicians to provide high-quality care in a cost-effective way has never been greater.While the medical education system equips doctors with skills to provide safe clinical care, it should also provide an understanding of healthcare costs and cost-effectiveness analysis.Value-based care is becoming a key paradigm in women’s health services, where clinicians must employ strategies for delivering value, rationalising costs and capitalising on the use of emerging technologies.The calculation of value of an intervention for providers and service users may differ; care must be taken to ensure this concept is adapted for, and not imposed on healthcare systems.Engaging trainees in systems transformation and embedding the concepts of ‘do no financial harm’ are essential to ensure sustainable healthcare services.Learning ObjectivesTo understand the principles of value-based health care.To highlight the importance of adopting ‘cost-conscious’ care within daily clinical practice.To learn the differences between ‘cost’, ‘charge’, ‘price’ and ‘reimbursement.To encourage developing value-based competencies for future medical workforce through utilising out of programme placements and digital resources.Ethical IssuesThe ethical obligation of clinicians to consider cost may encompass justice and equity. However, the impact of practicing value-based health care is yet to be evaluated.
Girardelli S, Mullins E, Lees CC, 2021, COVID-19 and pregnancy: Lessons from 2020., Early Human Development, Vol: 162, Pages: 1-6, ISSN: 0378-3782
The outbreak and spread of the coronavirus disease 2019 pandemic has led to an unprecedented wealth of literature on the impact of human coronaviruses on pregnancy. The number of case studies and publications alone are several orders of magnitude larger than those published in all previous human coronavirus outbreaks combined, enabling robust conclusions to be drawn from observations for the first time. However, the importance of learning from previous human coronavirus outbreaks cannot be understated. In this narrative review, we describe what we consider to the major learning points arising from the SARS-CoV-2 pandemic in relation to pregnancy, and where these confound what might have been expected from previous coronavirus outbreaks.
Mullins E, 2021, Setting up post birth contraception services in NW London
FSRH eBulletin. In this month’s eFeature, Dr Edward Mullins, together with midwifery, obstetrics and SRH colleagues, describes the process of setting up a new clinical service to introduce post birth contraception for all women in North West London. They outline the considerations and requirements at each stage of developing the service, including staffing and other resources, building a business case for a sustaining the service and using routine clinical datasets to support service evaluation and improvement
Mullins E, Sharma S, McGregor A, 2021, Postnatal exercise interventions: a systematic review of adherence and effect, BMJ Open, Vol: 11, Pages: 1-10, ISSN: 2044-6055
Objective to evaluate adherence to and effect of postnatal physical activity (PA) interventions.Design systematic review of PA intervention randomised controlled trials in postnatal women. The initial search was carried out in September 2018, and updated in January 2021.Data sources Embase, MEDLINE, and Cochrane Central Register of Controlled Trials (CENTRAL) databases, hand-searching references of included studies. The 25 identified studies included 1466 postnatal women in community and secondary care settings.Eligibility criteria studies were included if the PA interventions were commenced and assessed in the postnatal year. Data extraction and synthesis data was extracted using a pre-specified extraction template and assessed independently by two reviewers using Cochrane ROB 1 tool.Results 1413 records were screened for potential study inclusion, full-text review was performed on 146 articles, 25 studies were included. The primary outcome was adherence to PA intervention. The secondary outcomes were the effect of the PA interventions on the studies’ specified primary outcome. We compared effect on primary outcome for supervised and unsupervised exercise interventions. Studies were small, median N= 66 (20-130). PA interventions were highly variable, targets for PA per week ranged from 60 -275 minutes per week. LTFU was higher (14.5% vs 10%) and adherence to intervention was lower (73.6% vs. 86%) for unsupervised vs. supervised studies.Conclusions studies of PA interventions inconsistently reported adherence and LTFU. Where multiple studies evaluated PA as an outcome, they had inconsistent effects, with generally low study quality and high risk of bias. Agreement for effect between studies was evident for PA improving physical fitness and reducing fatigue. Three studies showed no adverse effect of physical activity on breast feeding. High-quality research reporting adherence and LTFU is needed into how and when to deliver postnatal PA interventions to benefi
Mylrea-Foley B, Arabin B, Bergman E, et al., 2021, Perinatal and 2 year neurodevelopmental outcome in late preterm fetal compromise, BMJ Open, ISSN: 2044-6055
Introduction Following the detection of fetal growth restriction, there is no consensus about the criteria that should trigger delivery in the late preterm period. The consequences of inappropriate early or late delivery are potentially important yet practice varies widely around the world, with abnormal findings from fetal heart rate monitoring invariably leading to delivery. Indices derived from fetal cerebral Doppler examination may guide such decisions although there are few studies in this area. We propose a randomised, controlled trial to establish the optimum method of timing delivery between 32 weeks and 36 weeks 6 days of gestation. We hypothesise that delivery on evidence of cerebral blood flow redistribution reduces a composite of perinatal poor outcome, death and short-term hypoxia-related morbidity, with no worsening of neurodevelopmental outcome at 2 years.Methods and Analysis Women with non-anomalous singleton pregnancies 32+0 to 36+6 weeks of gestation in whom the estimated fetal weight or abdominal circumference is <10th percentile or has decreased by 50 percentiles since 18-32 weeks will be included for observational data collection. Participants will be randomised if cerebral blood flow redistribution is identified, based on umbilical to middle cerebral artery pulsatility index ratio (UCR) values. Computerised cardiotocography (cCTG) must show normal fetal heart rate short term variation (STV ≥4.5msec) and absence of decelerations at randomisation. Randomisation will be 1:1 to immediate delivery or delayed delivery (based on cCTG abnormalities or other worsening fetal condition). The primary outcome is poor condition at birth and/or fetal or neonatal death and/or major neonatal morbidity, the secondary non-inferiority outcome is two-year infant general health and neurodevelopmental outcome based on the Parent Report of Children's Abilities-Revised (PARCA-R) questionnaire. Ethics and Dissemination The Study Coordination Centre has obtained ap
Laycock HC, Mullins E, 2021, The role of anaesthetists in women's health, Anaesthesia, Vol: 76, Pages: 3-5, ISSN: 0003-2409
Mullins E, Hudak ML, Banerjee J, et al., 2021, Pregnancy and neonatal outcomes of COVID-19: co-reporting of common outcomes from PAN-COVID and AAP SONPM registries, Ultrasound in Obstetrics and Gynecology, Vol: 57, Pages: 5733-581, ISSN: 0960-7692
OBJECTIVE: Few large cohort studies have reported data on maternal, fetal, perinatal and neonatal outcomes associated with SARS-CoV-2 infection in pregnancy. We report the outcome of infected pregnancies from a collaboration formed early during the pandemic between the investigators of two registries, the UK and global Pregnancy and Neonatal outcomes in COVID-19 (PAN-COVID) study and the US American Academy of Pediatrics Section on Neonatal Perinatal Medicine (AAP SONPM) National Perinatal COVID-19 Registry. METHODS: This was an analysis of data from the PAN-COVID registry (January 1st to July 25th 2020), which includes pregnancies with suspected or confirmed maternal SARS-CoV-2 infection at any stage in pregnancy, and the AAP SONPM National Perinatal COVID-19 registry (April 4th to August 8th 2020), which includes pregnancies with positive maternal testing for SARS-CoV-2 from 14 days before delivery to 3 days after delivery. The registries collected data on maternal, fetal, perinatal and neonatal outcomes. The PAN-COVID results are presented both overall for pregnancies with suspected or confirmed SARS-CoV-2 infection and separately in those with confirmed infection. RESULTS: We report on 4005 pregnant women with suspected or confirmed SARS-CoV-2 infection (1606 from PAN-COVID and 2399 from AAP SONPM). For obstetric outcomes, in PAN-COVID overall, those with confirmed infection in PAN-COVID and AAP SONPM, respectively, maternal death occurred in 0.5%, 0.5% and 0.2% of cases, early neonatal death in 0.2%, 0.3% and 0.3% of cases and stillbirth in 0.5%, 0.6% and 0.4% of cases. Delivery was pre-term (<37 weeks' gestation) in 12.0% of all women in PAN-COVID, in 16.2% of those women with confirmed infection in PAN-COVID and in 15.7% of women in AAP SONPM. Extremely preterm delivery (< 27 weeks' gestation) occurred in 0.5% of cases in PAN-COVID and 0.3% in AAP SONPM. Neonatal SARS-CoV-2 infection was reported in 0.8% of all deliver
Banerjee J, Mullins E, Townson J, et al., 2021, Pregnancy and Neonatal Outcomes in COVID-19: Study protocol for a global registry of women with suspected or confirmed SARS-CoV-2 infection in pregnancy and their neonates, understanding natural history to guide treatment and prevention, BMJ Open, Vol: 11, Pages: 1-6, ISSN: 2044-6055
Introduction: Previous novel coronavirus pandemics, Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS), observed an association of infection in pregnancy with pre-term delivery, stillbirth and increased maternal mortality. Coronavirus disease2019(COVID-19), caused by SARS-CoV-2 infection, is the largest pandemic in living memory. Rapid accrual of robust case data on women in pregnancy and their babies affected by suspectedCOVID-19or confirmed SARS-CoV-2 infection will inform clinical management and preventative strategies in the current pandemic and future outbreaks. Methods and analysis: The Pregnancy And Neonatal outcomes in COVID-19 (PAN-COVID) registry is an observational study collecting focussed data on outcomes of pregnant mothers who have had suspected COVID-19 in pregnancy or confirmed SARS-CoV-2 infection and their neonatesvia a web-portal. Amongst the women recruited to the PAN-COVID registry, the study will evaluate the incidence of:1. Miscarriage and pregnancy loss2. FGR and stillbirth 3. Pre-term delivery 4. Vertical transmission(suspected or confirmed) and early-onset neonatal SARS-CoV-2 infection Data will be centre based and collected on individual women and their babies. Verbal consent will be obtained, to reduce face-to-face contact in the pandemic whilst allowing identifiable data collection for linkage. Statistical analysis of the data will be carried out on a pseudonymised dataset by the study statistician. Regular reports will be distributed to collaborators on the study research questions. Ethics and dissemination: This study has received research ethics approval in the UK. For international centres, evidence of appropriate local approval will be required to participate, prior to entry of data to the database. The reports will be published regularly. The outputs of the study will be regularly disseminated to 4participants and collaborators on the study
Mullins E, Hudak ML, Banerjee J, et al., 2021, Pregnancy and neonatal outcomes of COVID-19 – co-reporting of common outcomes from the PAN-COVID and AAP SONPM registry
<jats:title>Abstract</jats:title><jats:sec><jats:title>Background</jats:title><jats:p>Few large, cohort studies report data on individual’s maternal, fetal, perinatal, and neonatal outcomes associated with SARS-CoV-2 infection in pregnancy. We report outcomes from a collaboration formed early during the pandemic between the investigators of two registries, the UK and global Pregnancy and Neonatal outcomes in COVID-19 (PAN-COVID) study and the US American Academy of Pediatrics Section on Neonatal Perinatal Medicine (AAP SONPM) National Perinatal COVID-19 Registry.</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>PAN-COVID (suspected or confirmed SARS-CoV-2 infection at any stage in pregnancy) and the AAP SONPM registry (positive maternal testing for SARS-CoV-2 from 14 days before delivery to 3 days after delivery) studies collected data on maternal, fetal, perinatal and neonatal outcomes. PAN-COVID results are presented as all inclusions and those with confirmed SARS-CoV-2 infection only.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>We report 4004 women in pregnancy affected by suspected or confirmed SARS-CoV-2 infection (1606 from PAN-COVID and 2398 from the AAP SONPM) from January 1<jats:sup>st</jats:sup> 2020 to July 25<jats:sup>th</jats:sup> 2020 (PAN-COVID) and August 8<jats:sup>th</jats:sup> (AAP SONPM). For obstetric outcomes in PAN-COVID and AAP SONPM, respectively, maternal death occurred in 0.5% and 0.17%, early neonatal death in 0.2% and 0.3%, and stillbirth in 0.50% and 0.65% of women. Delivery was pre-term (<37 weeks gestation) in 12% of all women in PAN-COVID, in 16.2% of those women with confirmed infection in PAN-COVID and 16.2% of women in AAP SONPM. Very preterm delivery (< 27 weeks’ gestation) occurred in 0.6% in PAN-COVID and 0.7% in AAP
Mehta NS, Mytton OT, Mullins EWS, et al., 2020, SARS-CoV-2 (COVID-19): What do we know about children? A systematic review., Clinical Infectious Diseases, Vol: 71, Pages: 2469-2479, ISSN: 1058-4838
BACKGROUND: Few paediatric cases of COVID-19 have been reported and we know little about the epidemiology in children, though more is known about other coronaviruses. We aimed to understand the infection rate, clinical presentation, clinical outcomes and transmission dynamics for SARS-CoV-2, in order to inform clinical and public health measures. METHODS: We undertook a rapid systematic review and narrative synthesis of all literature relating to SARS-CoV-2 in paediatric populations. The search terms also included SARS-CoV and MERS-CoV. We searched three databases and the COVID-19 resource centres of eleven major journals and publishers. English abstracts of Chinese language papers were included. Data were extracted and narrative syntheses conducted. RESULTS: 24 studies relating to COVID-19 were included in the review. Children appear to be less affected by COVID-19 than adults by observed rate of cases in large epidemiological studies. Limited data on attack rate indicate that children are just as susceptible to infection. Data on clinical outcomes are scarce but include several reports of asymptomatic infection and a milder course of disease in young children, though radiological abnormalities are noted. Severe cases are not reported in detail and there are little data relating to transmission. CONCLUSIONS: Children appear to have a low observed case rate of COVID-19 but may have similar rates to adults of infection with SARS-CoV-2. This discrepancy may be because children are asymptomatic or too mildly infected to draw medical attention, be tested and counted in observed cases of COVID-19.
Stampalija T, Thornton J, Marlow N, et al., 2020, Fetal cerebral Doppler changes and outcome in late preterm fetal growth restriction: prospective cohort study, Ultrasound in Obstetrics and Gynecology, Vol: 56, Pages: 173-181, ISSN: 0960-7692
ObjectivesTo explore the association between fetal umbilical and middle cerebral artery (MCA) Doppler abnormalities and outcome in late preterm pregnancies at risk of fetal growth restriction.MethodsThis was a prospective cohort study of singleton pregnancies at risk of fetal growth restriction at 32 + 0 to 36 + 6 weeks of gestation, enrolled in 33 European centers between 2017 and 2018, in which umbilical and fetal MCA Doppler velocimetry was performed. Pregnancies were considered at risk of fetal growth restriction if they had estimated fetal weight and/or abdominal circumference (AC) < 10th percentile, abnormal arterial Doppler and/or a fall in AC growth velocity of more than 40 percentile points from the 20‐week scan. Composite adverse outcome comprised both immediate adverse birth outcome and major neonatal morbidity. Using a range of cut‐off values, the association of MCA pulsatility index and umbilicocerebral ratio (UCR) with composite adverse outcome was explored.ResultsThe study population comprised 856 women. There were two (0.2%) intrauterine deaths. Median gestational age at delivery was 38 (interquartile range (IQR), 37–39) weeks and birth weight was 2478 (IQR, 2140–2790) g. Compared with infants with normal outcome, those with composite adverse outcome (n = 93; 11%) were delivered at an earlier gestational age (36 vs 38 weeks) and had a lower birth weight (1900 vs 2540 g). The first Doppler observation of MCA pulsatility index < 5th percentile and UCR Z‐score above gestational‐age‐specific thresholds (1.5 at 32–33 weeks and 1.0 at 34–36 weeks) had the highest relative risks (RR) for composite adverse outcome (RR 2.2 (95% CI, 1.5–3.2) and RR 2.0 (95% CI, 1.4–3.0), respectively). After adjustment for confounders, the association between UCR Z‐score and composite adverse outcome remained significa
Mylrea-Foley B, Bhide A, Mullins E, et al., 2020, Building consensus: thresholds for delivery in the TRUFFLE 2 randomized intervention study., Ultrasound in Obstetrics and Gynecology, Vol: 56, Pages: 285-287, ISSN: 0960-7692
Mullins E, Evans D, Viner RM, et al., 2020, Coronavirus in pregnancy and delivery: rapid review, ULTRASOUND IN OBSTETRICS & GYNECOLOGY, Vol: 55, Pages: 586-592, ISSN: 0960-7692
Mullins E, Evans D, Viner R, et al., 2020, Coronavirus in pregnancy and delivery: rapid review and expert consensus, Publisher: Cold Spring Harbor Laboratory
BACKGROUND Person to person spread of COIVD-19 in the UK has now been confirmed. There are limited case series reporting the impact on women affected by coronaviruses (CoV) during pregnancy. In women affected by SARS and MERS, the case fatality rate appeared higher in women affected in pregnancy compared with non-pregnant women. We conducted a rapid, review to guide management of women affected by COVID -19 during pregnancy and developed interim practice guidance with the RCOG and RCPCH to inform maternity and neonatal service planningMETHODS Searches were conducted in PubMed and MedRxiv to identify primary case reports, case series, observational studies or randomised-controlled trial describing women affected by coronavirus in pregnancy and on neonates. Data was extracted from relevant papers and the review was drafted with representatives of the RCPCH and RCOG who also provided expert consensus on areas where data were lackingRESULTS From 9964 results on PubMed and 600 on MedRxiv, 18 relevant studies (case reports and case series) were identified. There was inconsistent reporting of maternal, perinatal and neonatal outcomes across case reports and series concerning COVID-19, SARS, MERS and other coronaviruses. From reports of 19 women to date affected by COVID-19 in pregnancy, delivering 20 babies, 3 (16%) were asymptomatic, 1 (5%) was admitted to ICU and no maternal deaths have been reported. Deliveries were 17 by caesarean section, 2 by vaginal delivery, 8 (42%) delivered pre-term. There was one neonatal death, in 15 babies who were tested there was no evidence of vertical transmission.CONCLUSIONS Morbidity and mortality from COVID-19 appears less marked than for SARS and MERS, acknowledging the limited number of cases reported to date. Pre-term delivery affected 42% of women hospitalised with COVID-19, which may put considerable pressure on neonatal services if the UK reasonable worse-case scenario of 80% of the population affected is realised. There has been
Mullins E, Lees C, Brocklehurst P, 2017, Is continuous electronic fetal monitoring useful for all women in labour?, BMJ, Vol: 359, ISSN: 0959-8138
Routine monitoring of all women would prevent much neonatal morbidity, argue Edward Mullins and Christoph Lees, but Peter Brocklehurst believes that it will increase the risk of harm from unnecessary caesarean sections.
Hanson M, Mullins E, Modi N, 2017, Time for the UK to commit to tackling child obesity, BMJ, Vol: 356, ISSN: 1756-1833
The UK government published its report Childhood Obesity: a Plan for Action, after a protracted delay, on 18 August 2016, when parliament was in recess and the nation was focused on the success of Team GB at the Rio Olympics.1 The plan received very little media coverage or public response. There was, however, an immediate outcry from the medical and public health communities, who had hoped for much more.23456 The draft version had been 50 pages in length, but the published plan ran to just 10 pages; strong actions were conspicuous by their absence, and the desired discussion of anti-obesogenic medicine had been watered down to an emphasis on voluntary actions by industry, consumers, and schools.One of the most important omissions was reference to the recommendations of the World Health Organization Commission on Ending Childhood Obesity (ECHO).7 The final ECHO report, published in January 2016, was the culmination of about 18 months of evidence review and wide consultation. It was presented at the World Health Assembly in May 2016,8 where a decision was made to request the director general to develop an implementation plan to guide further action on the recommendations, in consultation with member states. The implementation report is now available.
Mullins E, Murphy O, Davies SC, 2016, Pre-conception public health to address maternal obesity, BJOG-AN INTERNATIONAL JOURNAL OF OBSTETRICS AND GYNAECOLOGY, Vol: 123, Pages: 159-160, ISSN: 1470-0328
Davies SC, Mullins E, 2015, Annual Report of the Chief Medical Officer, 2014, The Health of the 51%: Women, Annual Report of the Chief Medical Officer, 2014 The Health of the 51%: Women, London, Publisher: Department of Health
Independent reportChief Medical Officer annual report 2014: women’s healthContains analysis of, and recommendations on, a range of women's health issues, including obesity, cancer and reproductive health.
Mullins EWS, Agarwal N, Oliver R, et al., 2015, Implications of perihepatic adhesions in women undergoing laparoscopic surgery for ectopic pregnancy, Int J Gynaecol Obstet.
Mullins EWS, Story L, Sankaran S, et al., 2015, Survival of pregnancies with small for gestational age detected before 24 weeks gestation., European Journal of Obstetrics and Gynecology and Reproductive Biology, ISSN: 0301-2115
Prior T, Mullins E, Bennett P, et al., 2014, Influence of parity on fetal hemodynamics and amniotic fluid volume at term, ULTRASOUND IN OBSTETRICS & GYNECOLOGY, Vol: 44, Pages: 688-692, ISSN: 0960-7692
Prior T, Mullins E, Bennett P, et al., 2014, Are 1st-trimester beta-human chorionic gonadotrophin and pregnancy-associated plasma protein A levels predictive of intrapartum fetal compromise in a selected normal population?, AUSTRALIAN & NEW ZEALAND JOURNAL OF OBSTETRICS & GYNAECOLOGY, Vol: 54, Pages: 418-423, ISSN: 0004-8666
Prior T, Mullins E, Bennett P, et al., 2014, Umbilical venous flow rate in term fetuses: can variations in flow predict intrapartum compromise?, AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY, Vol: 210, ISSN: 0002-9378
Mullins E, Prior T, Roberts I, et al., 2013, Changes in the Fetal and Neonatal Cytokine Profile in Pregnancies Complicated by Fetal Growth Restriction, AMERICAN JOURNAL OF REPRODUCTIVE IMMUNOLOGY, Vol: 69, Pages: 441-448, ISSN: 1046-7408
Prior T, Wild M, Mullins E, et al., 2013, Sex specific differences in fetal middle cerebral artery and umbilical venous doppler, PLoS One, Vol: 8, Pages: 1-5, ISSN: 1932-6203
BackgroundThe incidence of several adverse pregnancy outcomes including fetal growth restriction are higher in pregnancies where the fetus is male, leading to suggestions that placental insufficiency is more common in these fetuses. Placental insufficiency associated with fetal growth restriction may be identified by multi-vessel Doppler assessment, but little evidence exists regarding sex specific differences in these Doppler indices or placental function. This study aims to investigate sex specific differences in fetal and placental perfusion and to correlate these changes with intra-partum outcome.Methods and FindingsThis is a prospective cohort study. We measured Doppler indices of 388 term pregnancies immediately prior to the onset of active labour (≤3 cm dilatation). Fetal sex was unknown at the time of the ultrasound assessment. Information from the ultrasound scan was not made available to clinical staff. Case notes and electronic records were reviewed following delivery. We report significantly lower Middle Cerebral artery pulsatility index (1.34 vs. 1.43, p = 0.004), Middle Cerebral artery peak velocity (53.47 cm/s vs. 58.10 cm/s, p = <0.001), and Umbilical venous flow/kg (56 ml/min/kg vs. 61 ml/min/kg, p = 0.02) in male fetuses. These differences however, were not associated with significant differences in intra-partum outcome.ConclusionSex specific differences in feto-placental perfusion indices exist. Whilst the physiological relevance of these is currently unknown, the identification of these differences adds to our knowledge of the physiology of male and female fetuses in utero. A number of disease processes have now been shown to have an association with changes in fetal haemodynamics in-utero, as well as having a sex bias, making further investigation of the sex specific differences present during fetal life important. Whilst the clinical application of these findings is currently limited, the results from this study do provide further insight
Prior T, Mullins E, Bennett P, et al., 2013, Prediction of intrapartum fetal compromise using the cerebroumbilical ratio: a prospective observational study, AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY, Vol: 208, ISSN: 0002-9378
Mullins E, Prior T, Roberts I, et al., 2012, Changes in the maternal cytokine profile in pregnancies complicated by fetal growth restriction, AMERICAN JOURNAL OF REPRODUCTIVE IMMUNOLOGY, Vol: 68, Pages: 1-7, ISSN: 1046-7408
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