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   Table of Contents - Current issue
January-March 2022
Volume 38 | Issue 1
Page Nos. 1-102

Online since Wednesday, March 30, 2022

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From the editor's desk p. 1
Nitin Gupta
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Mental health in an unequal world - The role of social determinants p. 3
Roy Abraham Kallivayalil, Arun Enara
The world, particularly in the past decade was shaped by events that exposed the drastic inequalities in modern-day societies. The social scientists and policy makers have looked at the interactions between these inequalities and health/illness. These interactions play a key role in the prevention, precipitation and treatment outcomes of mental health problems. The relevance of social determinants are often shaped by public policies that is a reflection of prevailing political ideologies. Adding to the problem is also a chronic underfunding in mental health creating a mental health treatment gap. Tackling these inequalities and understanding these social determinants, particularly in mental health and illness, will be key in the years ahead. The article will look to explore the social determinants, especially in the context of mental illness, in this unequal world.
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Does therapeutic alliance help “in search for meaning?” Experiences of working through a “Trilogy” p. 7
Aniruddha Basu
Background: Therapeutic alliance has been the 'Holy-Grail' of doctor patient relationship but is most discussed in relation to psychotherapy. At times in an individual therapeutic scenario it has been conceptualized as a working alliance to a collaborative plan but more than that it influences the lives of the clients and the therapists alike. Aims and Objectives: Understanding therapeutic alliance and its influence on the client and the therapist. Materials and Method: Three interrelated cases scenarios and the therapeutic alliance has been allegorized through the Shakespearian perspective. Results: In this exposition, a trilogy of three interrelated therapeutic case scenarios culminates in the existential framework. The first gentleman was a middle aged physician who had everything in life and at the end was drinking heavily as he had nothing else to do. In the second a soldier who fought bravely for his country but received no recognition and in lieu lost an arm in an conflict with the insurgents. Thereafter he found drinking as the only way forward. In the third case a gentleman who had alcohol dependence could quit alcohol unlike the other two. The main driving force of the latter was to do something for his son – this 'search for meaning' was lacking in the previous two. In the course it was seen that therapeutic alliance not only influences the life perspectives of the clients but also the therapist alike through an interplay of transference and counter transference. Conclusion: The influence of therapeutic alliance is not only limited to some narrow therapeutic scenarios but extends beyond in a much broader sense.
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Stepped care model for developing pathways of screening, referral, and brief intervention for depression in pregnancy: A mixed-method study from development phase p. 12
Prerna Kukreti, Ramdas Ransing, Pracheth Raghuveer, Mahesh Mahdevaiah, Smita N Deshpande, Dinesh Kataria, Manju Puri, Omsai Ramesh Vallamkonda, Sumit Rana, Harish K Pemde, Reena Yadav, Shilpi Nain, Shiv Prasad, Bhavuk Garg
Background: Depression in pregnancy affects nearly one in five women in low- and middle-income countries and is associated with adverse obstetric and neonatal outcome. Burden of morbidity is high, but specialized mental health resources are meager. Effective low intensity psychosocial interventions hold promise to fill the treatment gap for maternal depression. In this paper, we aim to describe the process of development of a stepped care model incorporating screening, providing brief intervention, and referral pathways developed for managing depression in pregnancy in antenatal care health facilities in India. Methodology: Using complex intervention development and evaluation method of Medical Research Council, United Kingdom, we searched evidence-based strategies from preexisting manuals, conducted formative research for need assessment and stakeholder engagement, and developed the intervention following an expert review panel. We conducted pilot testing to assess the feasibility and acceptability of intervention supplemented by three focused group discussions. Results: Manual review identified psychoeducation, empathetic listening, behavior activation, and supportive counseling as important elements. Need assessment revealed huge gap in perinatal mental health knowledge. Nearly 92% of total 272 perinatal women had poor awareness and 35%–70% of total 62 health-care providers had poor knowledge. In qualitative interview, women reported depressive symptoms as a normal part of pregnancy and had poor help seeking, behavior symptoms of depression were more prominent. A stepped care algorithm was developed for screening all expectant mothers in each trimester for depression using Patient Health Questionnaire-9 (PHQ-9). Women with PHQ-9 score >19 or reporting self-harm ideation were urgently referred to psychiatrist. Women with PHQ-9 score 5–19 were given brief intervention for depression in pregnancy intervention by antenatal nurse. The intervention developed consists of three sessions of psychoeducation, relaxation exercise, and mental health promotion, each lasting 20 min and at gap of 2 weeks each. Service providers and mothers reported good acceptability of psychosocial intervention and reported satisfaction with content and delivery of intervention. Conclusion: Low intensity brief psychosocial interventions can be adapted for implementation if relevant stakeholders are engaged at each step right from development of such as screening, intervention pathway to delivery, and effectiveness study.
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Impact and facilitators of a psychiatric rehabilitation daycare work program: A qualitative study p. 21
Amrita Roy, Thanapal Sivakumar, Deepak Jayarajan
Background: Work confers many benefits to persons with psychiatric disabilities. The daycare work programs can be helpful for patients in multiple ways. Many stakeholders plan and implement a daycare work program, including patients, caregivers, trainers, staff members, and professionals. The literature on daycare work programs is limited. The present study aimed to understand the impact and facilitators of a selected daycare work program (Green Skills Program [GSP]) from the lens of stakeholders. Methods: Criterion sampling was used to recruit the stakeholders who have been part of GSP. Twenty-seven stakeholders were interviewed using a researcher-prepared semi-structured interview schedule. Atlas. ti version 9 was used for coding. Thematic analysis was done to identify themes. Results: Stakeholders considered GSP easy, enjoyable, and accommodative to patients with different functioning levels. GSP participation was deemed as gainful engagement and vital to day-structuring. The patients worked in groups, which promoted peer learning and teamwork. Various behavioral, social, and work-related improvements were noted among the patients by the stakeholders. Incentives and social reinforcements were significant motivators. Stakeholders were content with the trainer's way of teaching the patients and felt that she possessed many essential attributes that motivated them and improved their work outcomes. Conclusions: While conceiving daycare work programs, ease of doing activities, accommodation of patients with varying levels of functionality, trainer's aptitude, and use of reinforcements should be considered.
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Screen time and mental well-being of students during the COVID-19 pandemic: Findings from a survey among medical and engineering students p. 26
Ragul Ganesh, Swarndeep Singh, Rachna Bhargava, Yatan Pal Singh Balhara
Background and Objectives: Concerns have been expressed about the possible adverse impact of increased screen time on the psychological well-being of students during the COVID-19 pandemic. The current study aimed to assess the relationship between screen time and mental well-being among college students. Methods: This cross-sectional online survey-based study was conducted among Indian college students. Details regarding sociodemographics and the amount and pattern of screen time usage and mental well-being (assessed using World Health Organization Well-Being Index; 5) were collected. Furthermore, personality traits were assessed using a validated questionnaire. Results: The final study sample comprised of 731 medical and engineering undergraduate students with a mean age of 20.7 years. The total screen time across different devices among the study participants for both weekdays and weekends was comparable, with a median value of 540 min. Poor mental well-being was significantly associated with higher total screen time (P = 0.03). Furthermore, screen time use predominantly to access social media for noncommunication purposes was associated with significantly lower mental well-being scores (P = 0.03). Conclusions: The current study highlights the impact of screen time on the mental well-being of students. The higher total screen time use was associated with poor mental well-being. Various types of screen time could have a differential relation with the mental well-being of students. Increased screen time use predominantly to access social media for noncommunication purposes was associated with a higher risk of poor mental well-being.
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Common barriers and facilitators of addiction treatment among treatment-seeking population p. 32
Ankita Chattopadhyay, Siddharth Sarkar, Piyali Mandal, Esha Sood, Ankush Thakur
Background and Aims: In the process of treatment for substance use disorders, patients experience many barriers and facilitators related to treatment. This study aimed to ascertain the barriers and facilitators of addiction treatment in treatment-seeking population of patients with substance use disorders. Methods: A defined questionnaire was developed on the basis of qualitative work to assess the barriers and facilitators among adult patients with opioid and/or alcohol use disorders seeking care at a dedicated addiction treatment facility. Results: We recruited a total of 96 male patients. The mean age of the sample was 30.8 years. The most common barriers were feeling like taking substances when depressed, stressed, or angry; having difficulty while not having substances; and lack of willpower to quit the substances. The most common facilitators of treatment were quitting addiction for a better future (e.g., marriage and children); good response from the doctor; facing the harmful consequences of substance use; having effective medicine and treatment; substance use causing health deterioration; and the need to fulfill family responsibilities. Higher educational attainment and better socioeconomic status were associated with fewer barriers and facilitators of treatment. Conclusion: Some barriers and facilitators are endorsed more commonly by patients who seek services for addiction treatment. Efforts are required to minimize the barriers and utilize facilitators so that patients are able to engage in treatment more easily.
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Determinants of poor outcome of conduct disorder among children and adolescents: A 1-year follow-up study p. 38
Raghavan Jayaprakash, S Sharija, Prabhakaran Anil, K Rajamohanan
Background: Conduct disorder (CD) is a heterogeneous disorder with variations in symptomatology and outcome. Slightly more than half of CD ceases to meet the criteria for CD during late childhood or adolescence. Many studies had examined the factors that determine the outcome of CD. However, limited follow-up studies are available in the Indian context. The present study aims to identify the factors that determine the poor outcome of CD. Materials and Methods: This was a clinic-based follow-up study. The study population consists of 300 consecutive children between 6 and 18 years of age who satisfied the International Classification of Disease-10 Diagnostic Criteria for Research guidelines for CD. Study setting was behavioral pediatrics unit under tertiary care pediatric department. Recruited children were intervened and followed up for 1 year. Initial and final scores of abnormal psychosocial situation, symptom severity, and functional level were assessed. A percentage of children who achieved clinically significant improvement were noticed. Determinants of poor outcome were identified by logistic regression. Results: Clinically significant improvement was observed among 64.51% of sample. Determinants of poor outcome were family history of single parent, alcoholism, domestic violence, and psychiatric illness and duration, initial severity, and type of symptoms and comorbidity. Conclusions: CD is amenable to intervention in the Indian setting. Early intervention will give good outcome. Among risk factors identified, four were socially modifiable factors.
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A study of psychiatrists' attitudes and concerns toward the practice and stigma associated with electroconvulsive therapy p. 45
Parth Nagda, Devavrat Harshe, Sagar Karia, Sneha Harshe, Gurudas Harshe, Nilesh Shah, Avinash de Sousa
Background: Electroconvulsive therapy (ECT) has shown to have efficacy and safety in treating psychiatric disorders. Studies have shown psychiatrists harboring negative attitudes about its use. The aim of the study was to assess the attitudes of psychiatrists toward practice and use of ECT and stigma associated with it. Methodology: A self-designed questionnaire was mailed electronically. Participants were asked to rate their attitudes and experience of using ECT in practice, concerns faced during prescribing ECTs, and possible solutions for destigmatization of ECTs. Results: We received 483 valid responses. Majority had positive attitudes toward the current use of ECT. Practicing in a metropolitan city, working in multiple clinics, having a family history of psychiatric illness, and having a member of the family treated with ECTs were associated with significantly more positive attitude and less concern about ECT. Poor socio-occupational strata, poor financial status, poor educational status, diagnosis of psychosis, and history of suicidal illness were associated with better acceptance of ECT by patients and caregivers. Improving undergraduate education in psychiatry and ECT and organizing interactions between patients advised ECT and patients improved with ECT were felt as effective solutions to counter ECT-related stigma by most number of psychiatrists. Conclusions: Psychiatrists in India have positive attitudes toward ECT yet have major concerns about caregiver reactions and patient dropouts while prescribing ECT. Practice location and prior exposure to psychiatric illness and ECT affect attitudes toward ECT. Psychiatrists suggested multiple strategies to reduce stigma associated with ECTs, changing the name of ECT to a nonstigmatizing was one of them.
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Academic difficulties among young persons with mental disorders p. 52
A Akshaya, Subhashini Gopal, R Pavithra, Vijaya Raghavan
Background: Various factors contribute the poor academic performance and discontinuation from schools among young people with mental disorders. The present study aimed to identify the difficulties and barriers posed by mental disorders; coping strategies to overcome them, and consolidate the recommendations made by students with mental illness and their parents to make education friendlier for students with mental illness. Materials and Methods: Semi-qualitative study was conducted in the outpatient department of the Schizophrenia Research Foundation, a mental health center and nonprofit organization based in Chennai. All patients between 13 and 23 years with an International Classification of Diseases, Tenth Revision diagnosis of any psychiatric disorder, pursuing or discontinued studies within the last 2 years were included in the study. A qualitative interview pro forma was developed and used for interviewing the patients and their family members. Results: 60.3% of the individuals interviewed had a disruption in their academic endeavor lasting for a minimum period of 2 weeks wherein they could not attend class and 1–4 such disruptions per individual in the last 2 years. Major difficulties cited by the participants were the interference of illness symptoms in academic performance, stress caused by difficulties in meeting academic requirements, and interpersonal stressors. Recommendations proposed by the participants were directed toward strategies for compensating the cognitive deficits caused by mental illness and special provisions in the examinations and evaluation. Conclusion: Acknowledging the difficulties faced by the students with mental illness and providing feasible provisions and concessions can go a long way in ensuring the students with mental illness receive a complete education.
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Association of depression/anxiety and quality of life in patients with chronic kidney disease undergoing hemodialysis: a study from Western Rajasthan p. 58
Pankaj Gadia, Ghanshyam Das Koolwal, Ankit Awasthi
Context: Chronic kidney disease (CKD) is emerging as a public health problem globally. Depression and anxiety are commonly seen in patients with CKD who are undergoing hemodialysis, and these ailments deteriorate the quality of life (QoL) of these patients. Aims: The present study aimed to determine the association between depression/anxiety and QoL in CKD patients. Settings and Design: This cross-sectional study was conducted at the nephrology department of the institution on 100 patients with CKD undergoing hemodialysis, who fulfilled the inclusion criteria for this study. Informed consent was taken prior to enrollment for the study. Materials and Methods: After seeking sociodemographic information, the Hospital Anxiety and Depression Scale was applied to screen for and to assess the severity of anxiety and depression, while the World Health Organization-QOL Assessment BREF questionnaire was administered to measure the subjective QoL. Data collected were subjected to suitable statistical analysis. Results: The prevalence of depression and anxiety among CKD patients was 66% and 61%, respectively. CKD patients with depression and anxiety had worse scores on all domains of QoL questionnaire. Both depression and anxiety negatively correlated with all domains of QoL. Conclusions: Depression and anxiety are highly prevalent in patients with CKD, and patients afflicted with the above had impaired QoL.
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Coping and burden among caregivers of patients with major mental illness Highly accessed article p. 63
Varsha Thakur, Padmavathi Nagarajan, Ravi Philip Rajkumar
Background: A shorter duration of inpatient stay and early discharge from the hospital for mental illness has expanded the role of the caregiver. Many of the caregivers experience a substantial burden due to the additional responsibilities of caring for a mentally ill individual. Lack of coping ability may increase their level of burden. Materials and Methods: A cross-sectional, descriptive research design was used to investigate coping strategies and burden among the caregivers of patients with major mental illness and to assess the relationship between them. Caregivers of patients with major mental disorders – schizophrenia (n = 16), bipolar affective disorder (n = 15), and depression (n = 15) were recruited from the psychiatric services of a tertiary level hospital through the convenience sampling. The family burden interview schedule (FBIS) by Pai and Kapur and coping checklist was used to assess the level of burden and coping strategies, respectively. Results: The majority of caregivers (52.2%) experienced a moderate level of the burden as rated by the FBIS. Disruption of the family routine activities was found to be the domain with the highest burden score among caregivers. Only marginal differences in burden scores were found across diagnostic groups (schizophrenia, 1.75 ± 0.57 bipolar disorder and depression 1.86 ± 0.74). Problem-focused coping was the strategy most frequently used by caregivers. Conclusion: Regardless of diagnosis, caregivers of patients with major mental illness experience substantial burdens. Appropriate interventions could improve coping strategies and reduce the burden of caregivers. This, in turn, could lead to improved treatment outcomes in patients with major mental illness.
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Gender differences in somatic symptoms in patients with depression: A comparative study at tertiary care center in North India p. 69
Parth Singh Meena, Anubhuti Sharma, Mahendra Jain
Introduction: Women suffering from clinical depression often present with prominent somatic complaints. Epidemiological studies have found that the prevalence of somatic depression, but not pure depression, distinguished women from men. The purpose of the study is to evaluate whether somatic symptoms of depression are more prevalent in females than in males. Subjects and Methods: A cross-sectional analytic study was carried out at a tertiary level referral hospital attached to a medical college in Rajasthan by the department of psychiatry. Consecutive patients (both male and female) suffering from depression were recruited for the study, diagnosed as per the International Classification of Diseases-10. Eighty-two male and 86 female adult psychiatric outpatients with diagnosis of depressive disorder were assessed using Hamilton Depression Rating Scale (HDRS-17) and Somatic Symptom Scale-Adult (derived from Patient Health Questionnaire Physical Symptoms) to quantify the severity of depression and somatic symptoms, respectively, and compared. Data collected from the patients were analyzed using unpaired t-test and Fisher's exact test. 95% confidence interval and P ≤ 0.05 were used to indicate a significant difference between the groups. Results: No statistically significant difference was found in the severity of depression between male and female patients. Somatic symptom scores were higher in female patients, both on somatic symptom score and HAM-D. Conclusions: Higher prevalence of somatic depression was found in female patients suffering from depression.
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Effectiveness of Yoga Nidra Intervention (Meditation) in improving well-being of an individual p. 73
Manish Kumar Dwivedi
Objective: The present study has investigated the impact of Yoga Nidra in improving the wellbeing of an individual. Context: Thomas argued that there is no precise definition of well-being, and he argued that well-being is intangible, difficult to define, and even hard to measure. The impact of stress causes physical, cognitive, emotional, and behavioral disorders which result in deteriorating the well-being of an individual. Yoga Nidra relaxes the body at physical, mental, emotional, and spiritual levels. Methods: The comprehensive scale of well-being comprises these factors that are taken into consideration for assessing the well-being at these levels. The study investigated the well-being before and after the administration of Yoga Nidra intervention to the participants. This is a pre- and post test experimental study in which factors of well-being are being explored through extensive literature survey and instrument of well-being has been developed. The various factors were explored through exploratory factor analysis and validated it through confirmatory factor analysis. Results and Conclusion: The results showed that there is a significant influence of physical, mental, emotional, and spiritual components on well-being.
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Coping in caregivers of obsessive–compulsive disorders p. 86
Erika Pahuja, Anil Nischal, Anuradha Nischal, Manu Agarwal, Bandna Gupta, Adarsh Tripathi
Background: Obsessive Compulsive disorder (OCD) is potentially a disabling disorder not only for the patients, but also for their family members, generating an additional burden on caregivers. Burden of care on caregivers may impact their family dynamics and affect the course of the illness. This perception of burden may largely depend on the coping strategies used by the caregivers. Studies have demonstrated that coping varies with socio-demographic variables but there is a dearth of research on coping strategies used by caregivers of OCD in India. Aims: To study coping in caregivers of OCD and its association with socio-demographic variables of caregivers and clinical variables of the illness. Method: Sixty seven caregivers of OCD were assessed on Cope Inventory. Association of experience of coping with socio-demographic variables of caregivers as well as patients and clinical variables of patients was studied. Result and Conclusions: Adaptive coping strategies like “Positive reinterpretation and Growth” and “Active Coping” were used more by males; student, clerical/ shop owner/ farmer; and caregivers of patients with OCD, with mixed obsessional thoughts and acts. Maladaptive coping strategies like “Focus on Venting of Emotions” was used more by caregivers of patients with severe illness. “Acceptance” was used more by young caregivers, spouses and caregivers of patients who received adequate treatment for last 3 months. Considering, adaptive coping efforts may provide protection from stressor of having a family member with OCD, there is an equal need to focus on caregivers along with patients. Training caregivers to use adaptive coping strategies, family interventions, psycho-educating targeted caregivers may lower the burden of illness and help caregivers to appraise the caregiving more favorably rather than taxing.
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Psychiatric manifestation and occurrence of violence toward caregivers p. 93
Sweta , Bhupendra Singh, Praful P Kapse, Neha Jha, Upendra Singh
Background: Individuals diagnosed with schizophrenia or bipolar affective disorder (BAD) are not always violent or make violent responses. However, psychiatric disorders such as schizophrenia and BAD are associated with violent acts of patients in various forms such as physical, verbal, and emotional violence. The victims to these violent acts by individuals suffering from schizophrenia or BAD are the caregivers most of the times. In addition, the treating team experiences violence by psychiatric patients during their stay in the hospital, especially in the initial days of hospitalization. Materials and Methods: This study was a cross-sectional, descriptive research. A total of 104 caregivers were selected for the study as per the inclusion and exclusion criteria. Sociodemographic and clinical details were collected through semi-structured interview schedule. Data were collected including sociodemographic details, Family Violence Scale, Family Burden Interview Schedule, and Depression Anxiety and Stress Scale. Results: The study states that caregivers of individuals diagnosed with schizophrenia or BAD experience overall burden. The experience is associated with being a victim of violence made by the relative suffering with psychiatric disorder. In addition, the events of violence create adverse impact on the psychological well-being of the caregivers, causing stress, anxiety, and depression. Conclusion: The study clearly indicates the need to attend the psychological needs of the caregivers of individuals suffering from schizophrenia or BAD.
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Parenting styles in borderline personality disorder: A pilot study p. 99
Apoorva Shrivastava, M Manjula, K John Vijaysagar, Harish Thippeswamy
Background: Personality disorders (PDs) are often influenced by early circumstances such as parenting. Parenting remains a subjective experience which has not been well studied in the context of PDs from the perspectives of parents and their children. Aims: This study examined the parenting styles in the form of perceived parenting in youth with borderline PD (BPD) and parenting experiences of their parents. Settings and Design: We employed a mixed-methods cross-sectional study design to assess youth aged between 16 and 24 years diagnosed with BPD and their parents, who sought treatment at a tertiary care psychiatric hospital. Methods: Youth (n = 5) and their parents (n = 8) were assessed on the Structured Clinical Interview for DSM 5 for PD, MINI International Neuropsychiatric Interview 7.0.2, and the Parenting Styles and Dimensions Questionnaire – Short Form. Two youth and two parents from the primary sample were selected for a semi-structured interview on parenting. Statistical Analysis: Parenting style scores were analyzed through descriptive statistics. Thematic analysis was used to interpret the interview data. Results: Youth with BPD perceived parenting as authoritarian and scored their parents lowest on the autonomy-granting dimension of authoritative parenting style. Verbal hostility was scored highest for parents. Parents of youth with BPD perceived their parenting style as authoritative, viewing themselves as warm and supportive. In the interviews, youth reported high criticality; they expressed dissatisfaction with parenting styles and need for support. The parents reported the negative influence of marital discord on parenting styles, and the need for open communication. Conclusions: Parenting styles are perceived differently by youth with BPD and their parents. Presence of psychopathology and individual personality traits of both youth and parents seem to play an important role in determining parenting,which needs further exploration.
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