Effectiveness of a Strategy to Improve Adherence to Tuberculosis Treatment in a Resource-Poor Setting: A Cluster Randomized Controlled Trial
CONTEXT Poor adherence to treatment remains a major obstacle to efficient tuberculosis (TB) control in developing countries. Innovative strategies to improve access and adherence to treatment are needed. OBJECTIVES To assess the effectiveness of a contextualized intervention strategy aimed at improv...
Gespeichert in:
| Veröffentlicht in: | JAMA : the journal of the American Medical Association 2007-01, Vol.297 (4), p.380-386 |
|---|---|
| Hauptverfasser: | , , , , , , , |
| Format: | Artikel |
| Sprache: | eng |
| Schlagworte: | |
| Online-Zugang: | Volltext |
| Tags: |
Tag hinzufügen
Keine Tags, Fügen Sie den ersten Tag hinzu!
|
| container_end_page | 386 |
|---|---|
| container_issue | 4 |
| container_start_page | 380 |
| container_title | JAMA : the journal of the American Medical Association |
| container_volume | 297 |
| creator | Thiam, Sylla LeFevre, Andrea M Hane, Fatoumata Ndiaye, Alimatou Ba, Fatoumata Fielding, Katherine L Ndir, Moustapha Lienhardt, Christian |
| description | CONTEXT Poor adherence to treatment remains a major obstacle to efficient tuberculosis (TB) control in developing countries. Innovative strategies to improve access and adherence to treatment are needed. OBJECTIVES To assess the effectiveness of a contextualized intervention strategy aimed at improving patients' adherence to treatment and to evaluate its impact on TB control in a resource-poor country in Africa with prevalent TB infection. DESIGN, SETTING, AND PATIENTS A cluster randomized controlled trial, conducted between June 2003 and January 2005, at 16 government district health centers in Senegal. Patients older than 15 years with newly diagnosed sputum smear–positive pulmonary TB were randomly assigned to the intervention or control group. INTERVENTION The intervention strategy included reinforced counseling through improved communication between health personnel and patients, decentralization of treatment, choice of directly observed therapy (DOT) supporter by the patient, and reinforcement of supervision activities. In the control group, the usual TB control program procedures remained unchanged. MAIN OUTCOME MEASURE Proportion of patients successfully completing the 8-month course of treatment and the proportion of patients defaulting from treatment. RESULTS A total of 1522 patients were recruited into the study. Treatment was successful for 682 (88%) of 778 patients recruited in the intervention group, and for 563 (76%) of 744 patients recruited in the control group (adjusted risk ratio [RR], 1.18; 95% confidence interval [CI], 1.03-1.34). The proportion of patients defaulting was reduced in the intervention group to 5.5% (n = 43) compared with 16.8% (n = 125) in the control group (adjusted RR, 0.43; 95% CI, 0.21-0.89). CONCLUSION The intervention package based on improved patients counseling and communication, decentralization of treatment, patient choice of DOT supporter, and reinforcement of supervision activities led to improvement in patient outcomes compared with the usual TB control procedures. This approach may be generalized in the context of TB control programs in resource-poor countries. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00412009 |
| doi_str_mv | 10.1001/jama.297.4.380 |
| format | Article |
| fullrecord | <record><control><sourceid>proquest_pubme</sourceid><recordid>TN_cdi_proquest_miscellaneous_68943494</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><ama_id>205285</ama_id><sourcerecordid>1222754931</sourcerecordid><originalsourceid>FETCH-LOGICAL-a315t-8dbb47ecbd5734f2b3be6637e0d2e30bac33d4371eb38583fd021b3fa4fedb2f3</originalsourceid><addsrcrecordid>eNqF0UFrFDEUAOAgil2rV8GLBEFvsyZ5mZ2Mt2WpWigo7XoekslLzTKT1CRTqL_BH22kq4IXAyEh-d4LL4-Q55ytOWP87UHPei36bi3XoNgDsuItqAbaXj0kK8Z61XRSyRPyJOcDq4ND95ic8E5IqUCuyI8z53As_hYD5kyjo5pelaQLXt_REun5fJPiLdKt_YoJw4i_DveLwTQuU8w-031CXWYMhfpQgy8xxyWN2HyOMdErLMWH63d0S3fTkgsmeqmDjbP_jpbuYigpTlPd7pPX01PyyOkp47Pjekq-vD_b7z42F58-nO-2F40G3pZGWWNkh6OxbQfSCQMGNxvokFmBwIweAayEjqMB1SpwlgluwGnp0Brh4JS8uc9ba_u2YC7D7POI06QDxiUPG9VLkHX-Dwq24bzvocJX_8BD_YVQixgE5yBqQlbRyyNazIx2uEl-1ulu-N2NCl4fgc6jnlzSYfT5r1Oyq2-11b24d7X5f24Fa4Vq4Sd17qMI</addsrcrecordid><sourcetype>Aggregation Database</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>211328940</pqid></control><display><type>article</type><title>Effectiveness of a Strategy to Improve Adherence to Tuberculosis Treatment in a Resource-Poor Setting: A Cluster Randomized Controlled Trial</title><source>MEDLINE</source><source>American Medical Association Journals</source><creator>Thiam, Sylla ; LeFevre, Andrea M ; Hane, Fatoumata ; Ndiaye, Alimatou ; Ba, Fatoumata ; Fielding, Katherine L ; Ndir, Moustapha ; Lienhardt, Christian</creator><creatorcontrib>Thiam, Sylla ; LeFevre, Andrea M ; Hane, Fatoumata ; Ndiaye, Alimatou ; Ba, Fatoumata ; Fielding, Katherine L ; Ndir, Moustapha ; Lienhardt, Christian</creatorcontrib><description>CONTEXT Poor adherence to treatment remains a major obstacle to efficient tuberculosis (TB) control in developing countries. Innovative strategies to improve access and adherence to treatment are needed. OBJECTIVES To assess the effectiveness of a contextualized intervention strategy aimed at improving patients' adherence to treatment and to evaluate its impact on TB control in a resource-poor country in Africa with prevalent TB infection. DESIGN, SETTING, AND PATIENTS A cluster randomized controlled trial, conducted between June 2003 and January 2005, at 16 government district health centers in Senegal. Patients older than 15 years with newly diagnosed sputum smear–positive pulmonary TB were randomly assigned to the intervention or control group. INTERVENTION The intervention strategy included reinforced counseling through improved communication between health personnel and patients, decentralization of treatment, choice of directly observed therapy (DOT) supporter by the patient, and reinforcement of supervision activities. In the control group, the usual TB control program procedures remained unchanged. MAIN OUTCOME MEASURE Proportion of patients successfully completing the 8-month course of treatment and the proportion of patients defaulting from treatment. RESULTS A total of 1522 patients were recruited into the study. Treatment was successful for 682 (88%) of 778 patients recruited in the intervention group, and for 563 (76%) of 744 patients recruited in the control group (adjusted risk ratio [RR], 1.18; 95% confidence interval [CI], 1.03-1.34). The proportion of patients defaulting was reduced in the intervention group to 5.5% (n = 43) compared with 16.8% (n = 125) in the control group (adjusted RR, 0.43; 95% CI, 0.21-0.89). CONCLUSION The intervention package based on improved patients counseling and communication, decentralization of treatment, patient choice of DOT supporter, and reinforcement of supervision activities led to improvement in patient outcomes compared with the usual TB control procedures. This approach may be generalized in the context of TB control programs in resource-poor countries. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00412009</description><identifier>ISSN: 0098-7484</identifier><identifier>EISSN: 1538-3598</identifier><identifier>DOI: 10.1001/jama.297.4.380</identifier><identifier>PMID: 17244834</identifier><identifier>CODEN: JAMAAP</identifier><language>eng</language><publisher>Chicago, IL: American Medical Association</publisher><subject>Adolescent ; Adult ; Antitubercular Agents - therapeutic use ; Bacterial diseases ; Biological and medical sciences ; Clinical trials ; Compliance ; Counseling ; Developing Countries ; Directly Observed Therapy ; Female ; General aspects ; Human bacterial diseases ; Humans ; Infectious diseases ; Intervention ; LDCs ; Male ; Medical sciences ; Medical treatment ; Middle Aged ; Mycobacterium ; Patient Compliance ; Patient Education as Topic ; Senegal ; Tuberculosis ; Tuberculosis and atypical mycobacterial infections ; Tuberculosis, Pulmonary - therapy</subject><ispartof>JAMA : the journal of the American Medical Association, 2007-01, Vol.297 (4), p.380-386</ispartof><rights>2007 INIST-CNRS</rights><rights>Copyright American Medical Association Jan 24-Jan 31, 2007</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://jamanetwork.com/journals/jama/articlepdf/10.1001/jama.297.4.380$$EPDF$$P50$$Gama$$H</linktopdf><linktohtml>$$Uhttps://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.297.4.380$$EHTML$$P50$$Gama$$H</linktohtml><link.rule.ids>64,314,780,784,3338,27923,27924,76260,76263</link.rule.ids><backlink>$$Uhttp://pascal-francis.inist.fr/vibad/index.php?action=getRecordDetail&idt=18479335$$DView record in Pascal Francis$$Hfree_for_read</backlink><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/17244834$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Thiam, Sylla</creatorcontrib><creatorcontrib>LeFevre, Andrea M</creatorcontrib><creatorcontrib>Hane, Fatoumata</creatorcontrib><creatorcontrib>Ndiaye, Alimatou</creatorcontrib><creatorcontrib>Ba, Fatoumata</creatorcontrib><creatorcontrib>Fielding, Katherine L</creatorcontrib><creatorcontrib>Ndir, Moustapha</creatorcontrib><creatorcontrib>Lienhardt, Christian</creatorcontrib><title>Effectiveness of a Strategy to Improve Adherence to Tuberculosis Treatment in a Resource-Poor Setting: A Cluster Randomized Controlled Trial</title><title>JAMA : the journal of the American Medical Association</title><addtitle>JAMA</addtitle><description>CONTEXT Poor adherence to treatment remains a major obstacle to efficient tuberculosis (TB) control in developing countries. Innovative strategies to improve access and adherence to treatment are needed. OBJECTIVES To assess the effectiveness of a contextualized intervention strategy aimed at improving patients' adherence to treatment and to evaluate its impact on TB control in a resource-poor country in Africa with prevalent TB infection. DESIGN, SETTING, AND PATIENTS A cluster randomized controlled trial, conducted between June 2003 and January 2005, at 16 government district health centers in Senegal. Patients older than 15 years with newly diagnosed sputum smear–positive pulmonary TB were randomly assigned to the intervention or control group. INTERVENTION The intervention strategy included reinforced counseling through improved communication between health personnel and patients, decentralization of treatment, choice of directly observed therapy (DOT) supporter by the patient, and reinforcement of supervision activities. In the control group, the usual TB control program procedures remained unchanged. MAIN OUTCOME MEASURE Proportion of patients successfully completing the 8-month course of treatment and the proportion of patients defaulting from treatment. RESULTS A total of 1522 patients were recruited into the study. Treatment was successful for 682 (88%) of 778 patients recruited in the intervention group, and for 563 (76%) of 744 patients recruited in the control group (adjusted risk ratio [RR], 1.18; 95% confidence interval [CI], 1.03-1.34). The proportion of patients defaulting was reduced in the intervention group to 5.5% (n = 43) compared with 16.8% (n = 125) in the control group (adjusted RR, 0.43; 95% CI, 0.21-0.89). CONCLUSION The intervention package based on improved patients counseling and communication, decentralization of treatment, patient choice of DOT supporter, and reinforcement of supervision activities led to improvement in patient outcomes compared with the usual TB control procedures. This approach may be generalized in the context of TB control programs in resource-poor countries. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00412009</description><subject>Adolescent</subject><subject>Adult</subject><subject>Antitubercular Agents - therapeutic use</subject><subject>Bacterial diseases</subject><subject>Biological and medical sciences</subject><subject>Clinical trials</subject><subject>Compliance</subject><subject>Counseling</subject><subject>Developing Countries</subject><subject>Directly Observed Therapy</subject><subject>Female</subject><subject>General aspects</subject><subject>Human bacterial diseases</subject><subject>Humans</subject><subject>Infectious diseases</subject><subject>Intervention</subject><subject>LDCs</subject><subject>Male</subject><subject>Medical sciences</subject><subject>Medical treatment</subject><subject>Middle Aged</subject><subject>Mycobacterium</subject><subject>Patient Compliance</subject><subject>Patient Education as Topic</subject><subject>Senegal</subject><subject>Tuberculosis</subject><subject>Tuberculosis and atypical mycobacterial infections</subject><subject>Tuberculosis, Pulmonary - therapy</subject><issn>0098-7484</issn><issn>1538-3598</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2007</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNqF0UFrFDEUAOAgil2rV8GLBEFvsyZ5mZ2Mt2WpWigo7XoekslLzTKT1CRTqL_BH22kq4IXAyEh-d4LL4-Q55ytOWP87UHPei36bi3XoNgDsuItqAbaXj0kK8Z61XRSyRPyJOcDq4ND95ic8E5IqUCuyI8z53As_hYD5kyjo5pelaQLXt_REun5fJPiLdKt_YoJw4i_DveLwTQuU8w-031CXWYMhfpQgy8xxyWN2HyOMdErLMWH63d0S3fTkgsmeqmDjbP_jpbuYigpTlPd7pPX01PyyOkp47Pjekq-vD_b7z42F58-nO-2F40G3pZGWWNkh6OxbQfSCQMGNxvokFmBwIweAayEjqMB1SpwlgluwGnp0Brh4JS8uc9ba_u2YC7D7POI06QDxiUPG9VLkHX-Dwq24bzvocJX_8BD_YVQixgE5yBqQlbRyyNazIx2uEl-1ulu-N2NCl4fgc6jnlzSYfT5r1Oyq2-11b24d7X5f24Fa4Vq4Sd17qMI</recordid><startdate>20070124</startdate><enddate>20070124</enddate><creator>Thiam, Sylla</creator><creator>LeFevre, Andrea M</creator><creator>Hane, Fatoumata</creator><creator>Ndiaye, Alimatou</creator><creator>Ba, Fatoumata</creator><creator>Fielding, Katherine L</creator><creator>Ndir, Moustapha</creator><creator>Lienhardt, Christian</creator><general>American Medical Association</general><scope>IQODW</scope><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>7QL</scope><scope>7QP</scope><scope>7TK</scope><scope>7TS</scope><scope>7U7</scope><scope>7U9</scope><scope>8FD</scope><scope>C1K</scope><scope>FR3</scope><scope>H94</scope><scope>K9.</scope><scope>M7N</scope><scope>NAPCQ</scope><scope>P64</scope><scope>RC3</scope><scope>7X8</scope></search><sort><creationdate>20070124</creationdate><title>Effectiveness of a Strategy to Improve Adherence to Tuberculosis Treatment in a Resource-Poor Setting: A Cluster Randomized Controlled Trial</title><author>Thiam, Sylla ; LeFevre, Andrea M ; Hane, Fatoumata ; Ndiaye, Alimatou ; Ba, Fatoumata ; Fielding, Katherine L ; Ndir, Moustapha ; Lienhardt, Christian</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-a315t-8dbb47ecbd5734f2b3be6637e0d2e30bac33d4371eb38583fd021b3fa4fedb2f3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2007</creationdate><topic>Adolescent</topic><topic>Adult</topic><topic>Antitubercular Agents - therapeutic use</topic><topic>Bacterial diseases</topic><topic>Biological and medical sciences</topic><topic>Clinical trials</topic><topic>Compliance</topic><topic>Counseling</topic><topic>Developing Countries</topic><topic>Directly Observed Therapy</topic><topic>Female</topic><topic>General aspects</topic><topic>Human bacterial diseases</topic><topic>Humans</topic><topic>Infectious diseases</topic><topic>Intervention</topic><topic>LDCs</topic><topic>Male</topic><topic>Medical sciences</topic><topic>Medical treatment</topic><topic>Middle Aged</topic><topic>Mycobacterium</topic><topic>Patient Compliance</topic><topic>Patient Education as Topic</topic><topic>Senegal</topic><topic>Tuberculosis</topic><topic>Tuberculosis and atypical mycobacterial infections</topic><topic>Tuberculosis, Pulmonary - therapy</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Thiam, Sylla</creatorcontrib><creatorcontrib>LeFevre, Andrea M</creatorcontrib><creatorcontrib>Hane, Fatoumata</creatorcontrib><creatorcontrib>Ndiaye, Alimatou</creatorcontrib><creatorcontrib>Ba, Fatoumata</creatorcontrib><creatorcontrib>Fielding, Katherine L</creatorcontrib><creatorcontrib>Ndir, Moustapha</creatorcontrib><creatorcontrib>Lienhardt, Christian</creatorcontrib><collection>Pascal-Francis</collection><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>Bacteriology Abstracts (Microbiology B)</collection><collection>Calcium & Calcified Tissue Abstracts</collection><collection>Neurosciences Abstracts</collection><collection>Physical Education Index</collection><collection>Toxicology Abstracts</collection><collection>Virology and AIDS Abstracts</collection><collection>Technology Research Database</collection><collection>Environmental Sciences and Pollution Management</collection><collection>Engineering Research Database</collection><collection>AIDS and Cancer Research Abstracts</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Algology Mycology and Protozoology Abstracts (Microbiology C)</collection><collection>Nursing & Allied Health Premium</collection><collection>Biotechnology and BioEngineering Abstracts</collection><collection>Genetics Abstracts</collection><collection>MEDLINE - Academic</collection><jtitle>JAMA : the journal of the American Medical Association</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Thiam, Sylla</au><au>LeFevre, Andrea M</au><au>Hane, Fatoumata</au><au>Ndiaye, Alimatou</au><au>Ba, Fatoumata</au><au>Fielding, Katherine L</au><au>Ndir, Moustapha</au><au>Lienhardt, Christian</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Effectiveness of a Strategy to Improve Adherence to Tuberculosis Treatment in a Resource-Poor Setting: A Cluster Randomized Controlled Trial</atitle><jtitle>JAMA : the journal of the American Medical Association</jtitle><addtitle>JAMA</addtitle><date>2007-01-24</date><risdate>2007</risdate><volume>297</volume><issue>4</issue><spage>380</spage><epage>386</epage><pages>380-386</pages><issn>0098-7484</issn><eissn>1538-3598</eissn><coden>JAMAAP</coden><abstract>CONTEXT Poor adherence to treatment remains a major obstacle to efficient tuberculosis (TB) control in developing countries. Innovative strategies to improve access and adherence to treatment are needed. OBJECTIVES To assess the effectiveness of a contextualized intervention strategy aimed at improving patients' adherence to treatment and to evaluate its impact on TB control in a resource-poor country in Africa with prevalent TB infection. DESIGN, SETTING, AND PATIENTS A cluster randomized controlled trial, conducted between June 2003 and January 2005, at 16 government district health centers in Senegal. Patients older than 15 years with newly diagnosed sputum smear–positive pulmonary TB were randomly assigned to the intervention or control group. INTERVENTION The intervention strategy included reinforced counseling through improved communication between health personnel and patients, decentralization of treatment, choice of directly observed therapy (DOT) supporter by the patient, and reinforcement of supervision activities. In the control group, the usual TB control program procedures remained unchanged. MAIN OUTCOME MEASURE Proportion of patients successfully completing the 8-month course of treatment and the proportion of patients defaulting from treatment. RESULTS A total of 1522 patients were recruited into the study. Treatment was successful for 682 (88%) of 778 patients recruited in the intervention group, and for 563 (76%) of 744 patients recruited in the control group (adjusted risk ratio [RR], 1.18; 95% confidence interval [CI], 1.03-1.34). The proportion of patients defaulting was reduced in the intervention group to 5.5% (n = 43) compared with 16.8% (n = 125) in the control group (adjusted RR, 0.43; 95% CI, 0.21-0.89). CONCLUSION The intervention package based on improved patients counseling and communication, decentralization of treatment, patient choice of DOT supporter, and reinforcement of supervision activities led to improvement in patient outcomes compared with the usual TB control procedures. This approach may be generalized in the context of TB control programs in resource-poor countries. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00412009</abstract><cop>Chicago, IL</cop><pub>American Medical Association</pub><pmid>17244834</pmid><doi>10.1001/jama.297.4.380</doi><tpages>7</tpages></addata></record> |
| fulltext | fulltext |
| identifier | ISSN: 0098-7484 |
| ispartof | JAMA : the journal of the American Medical Association, 2007-01, Vol.297 (4), p.380-386 |
| issn | 0098-7484 1538-3598 |
| language | eng |
| recordid | cdi_proquest_miscellaneous_68943494 |
| source | MEDLINE; American Medical Association Journals |
| subjects | Adolescent Adult Antitubercular Agents - therapeutic use Bacterial diseases Biological and medical sciences Clinical trials Compliance Counseling Developing Countries Directly Observed Therapy Female General aspects Human bacterial diseases Humans Infectious diseases Intervention LDCs Male Medical sciences Medical treatment Middle Aged Mycobacterium Patient Compliance Patient Education as Topic Senegal Tuberculosis Tuberculosis and atypical mycobacterial infections Tuberculosis, Pulmonary - therapy |
| title | Effectiveness of a Strategy to Improve Adherence to Tuberculosis Treatment in a Resource-Poor Setting: A Cluster Randomized Controlled Trial |
| url | https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-01-10T13%3A06%3A09IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-proquest_pubme&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Effectiveness%20of%20a%20Strategy%20to%20Improve%20Adherence%20to%20Tuberculosis%20Treatment%20in%20a%20Resource-Poor%20Setting:%20A%20Cluster%20Randomized%20Controlled%20Trial&rft.jtitle=JAMA%20:%20the%20journal%20of%20the%20American%20Medical%20Association&rft.au=Thiam,%20Sylla&rft.date=2007-01-24&rft.volume=297&rft.issue=4&rft.spage=380&rft.epage=386&rft.pages=380-386&rft.issn=0098-7484&rft.eissn=1538-3598&rft.coden=JAMAAP&rft_id=info:doi/10.1001/jama.297.4.380&rft_dat=%3Cproquest_pubme%3E1222754931%3C/proquest_pubme%3E%3Curl%3E%3C/url%3E&disable_directlink=true&sfx.directlink=off&sfx.report_link=0&rft_id=info:oai/&rft_pqid=211328940&rft_id=info:pmid/17244834&rft_ama_id=205285&rfr_iscdi=true |