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   Table of Contents - Current issue
Coverpage
July-August 2019
Volume 61 | Issue 4
Page Nos. 325-428

Online since Tuesday, July 16, 2019

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EDITORIAL  

Violence against doctors in India – Safety versus service p. 325
Om Prakash Singh
DOI:10.4103/psychiatry.IndianJPsychiatry_400_19  
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ORIGINAL ARTICLES Top

Safety and efficacy of adjunctive transcranial direct current stimulation in treatment-resistant obsessive-compulsive disorder: An open-label trial p. 327
Satish Kumar, Nand Kumar, Rohit Verma
DOI:10.4103/psychiatry.IndianJPsychiatry_509_18  
Introduction: The current pharmacological and psychotherapeutic approaches have limited benefit in symptom management of obsessive-compulsive disorder (OCD) urging clinicians and researchers to seek newer avenues of management. Transcranial direct current stimulation (tDCS) has shown promise in this aspect from a neuromodulatory perspective. The current study aims to study the response to tDCS as an adjunctive treatment in patients with treatment-resistant OCD. Materials and Methods: This open-label study was conducted among 20 patients with treatment-resistant OCD. All participants received 20 sessions of tDCS with the cathode at the supplementary motor area (SMA) and the anode at right occipital area. The primary outcome measure was the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and the secondary outcome was evaluated on the clinical global impression (CGI) and side effect checklist for tDCS. Results: There was a significant improvement from baseline in the mean scores of Y-BOCS and CGI scales after tDCS intervention. An improvement of >35% Y-BOCS score change was observed in 15% of participants. Short-lasting side effects were reported as mild headache and localized tingling sensation. Conclusion: Cathodal tDCS at SMA may be a useful approach to manage treatment-resistant OCD. The use of tDCS was not associated with any significant harmful consequence to the participants.
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Cognitive deficits, depressive symptoms, insight, and medication adherence in remitted patients with schizophrenia p. 335
V V Jagadeesh Settem, Haridas Karanadi, Samir Kumar Praharaj
DOI:10.4103/psychiatry.IndianJPsychiatry_17_19  
Objective: To study the relationship between cognitive deficits, depressive symptoms, insight, and medication adherence in remitted patients with schizophrenia. Methods: Fifty-four patients aged 18–60 years, with schizophrenia in remission, were evaluated for adherence using the Medication Adherence Rating Scale (MARS), cognitive deficits using the Schizophrenia Cognition Rating Scale (SCoRS), depressive symptoms using the Calgary Depression Scale for Schizophrenia (CDSS), and insight using the Beck Cognitive Insight Scale. Results: Twenty-one (38.9%) patients were found to be nonadherent to their medication. A significant negative correlation was found between MARS total score with SCoRS attention/vigilance (r = −0.28), attitude toward negative side effects of the psychotropic medication with SCoRS total score (r = −0.36), SCoRS attention/vigilance (r = −0.27), verbal learning and memory (r = −0.32), reasoning and problem-solving (r = −0.30), and social cognition (r = −0.28). A significant negative correlation was found between CDSS total score with MARS total score (r = −0.50), medication adherence behavior (r = −0.44), and attitude toward negative side effects of psychotropic medication (r = −0.60). MARS total score significantly positively correlated with years in remission (r = 0.29). Conclusions: Poor medication adherence was seen in more than one-third of remitted patients with schizophrenia and was associated with global cognitive deficits, depressive symptoms, and the number of years in remission.
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Medication adherence in first-episode psychosis and its association with psychopathology p. 342
Vijaya Raghavan, Greeshma Mohan, Subhashini Gopal, Mangala Ramamurthy, Thara Rangaswamy
DOI:10.4103/psychiatry.IndianJPsychiatry_148_17  
Background: The purpose of the study was to follow-up the individuals with first-episode psychosis (FEP) for a period of 1 year to assess their medication adherence rates and to identify the association between medication adherence and psychopathology. Materials and Methods: In a 1 year longitudinal study, 59 individuals with FEP were assessed for their sociodemographic profile and medication adherence at 1 month and 12-month follow-up period using a semi-structured per forma. Positive and negative symptoms were assessed by positive and negative syndrome scale (PANSS) while the functioning by global assessment of functioning (GAF) scale. Results: Nearly 85% of the individuals were adherent with medications during the 1-month follow-up period, 32.2% were poorly adherent at the end of 12 months. Among various factors examined for association with medication adherence, positive and negative symptoms, and global functioning of the individuals at the end of 12 months were found to significant associated with poor medication adherence. Conclusion: There is a high rate of medication nonadherence in individuals with FEP at 12-month follow-up, and factors affecting nonadherence should be addressed specifically to improve medication adherence in these individuals.
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Suicides of Punjabi hawkers in 19th- and early 20th-century Australia p. 347
Dirk H R Spennemann
DOI:10.4103/psychiatry.IndianJPsychiatry_379_17  
Background: During the late nineteenth century, a considerable number of young Punjabi men sought their fortunes in the Australian colonies, working as hawkers and farm labor. While in Australia they experienced marginalization and high levels of racial vilification by the Anglo-Celtic settler community. Aims: To assess the frequency and nature of suicides of Punjabi workers in nineteenth century Australia. Materials and Methods: The paper draws on archival sources and contemporary newspaper reports. Results: A wide range of methods of suicides were observed, with drowning the preferred method. Conclusions: This article is the first to collate the data on the suicides and suicide attempts by young Punjabi men working in an immigration country. It can be shown that the suicide rate among Punjabi was almost six times higher than that of the host community.
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Delirium in medical intensive care units: Incidence, subtypes, risk factors, and outcome p. 352
Ayush Kumar Jayaswal, Harshavardhan Sampath, Geeta Soohinda, Sanjiba Dutta
DOI:10.4103/psychiatry.IndianJPsychiatry_583_18  
Background: Delirium is a frequent yet underdiagnosed neuropsychiatric condition encountered in intensive care units (ICUs). Being both a preventable and potentially reversible process associated with significant morbidity and mortality, understanding risk factors that predispose and precipitate delirium in any given patient are critical in ICUs. Aims and Objectives: The aim of this study is to evaluate the incidence, motor subtypes, risk factors, and clinical outcome of delirium in the medical ICU. Materials and Methods: We used a prospective study design on a cohort of consecutive medical ICU admissions of a tertiary care teaching hospital. The Confusion Assessment Method-ICU and Richmond Agitation Sedation Scale were used to diagnose and motor subtype delirium, respectively, along with a checklist to assess risk factors. Results: Of the 280 ICU admissions, 88 (31.4%) developed delirium. Hypoactive delirium was the most common motor subtype (55.7%). The detection rate of delirium was 12.5% (lowest for hypoactive delirium at 2.04%). Age, gender, and years of education did not significantly predict delirium (all P > 0.05). Tobacco use, chronic liver disease, and past episodes of delirium significantly predisposed, while mechanical ventilation, hypoxia, fever, raised levels of bilirubin and creatinine, and benzodiazepine administration significantly precipitated ICU delirium. Delirium was significantly associated with longer ICU stay (t = 4.23, P = 0.000) and 1-month postdischarge mortality (χ2 = 6.867, P = 0.009). Conclusion: Detection of delirium is challenging, especially in ICU patients on mechanical ventilation and hypoactive delirium. Screening and monitoring for predisposing and precipitating risk factors can greatly improve the odds of detection and intervention as ICU delirium is associated with significant morbidity and mortality.
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Age of onset of substance use in patients with dual diagnosis and its association with clinical characteristics, risk behaviors, course, and outcome: A retrospective study p. 359
Bhagyalakshmi Nanjayya Subodh, Swapnajeet Sahoo, Debasish Basu, Surendra Kumar Mattoo
DOI:10.4103/psychiatry.IndianJPsychiatry_454_18  
Research Question: Do patients with dual diagnosis (DD) with an early initiation of substance use and subsequent early onset substance use disorder (EOS) differ from those with late onset substance use disorder (LOS) regarding characteristics, sex-related risk behaviors, course, and outcome? Objectives: The aim is to study EOS and LOS groups of patients with DD attending a treatment center with regard to clinical characteristics, type of psychiatric disorders, risk behaviors, and short-term outcome. Materials and Methods: Retrospective chart review of patients diagnosed with DD (n = 307) with regard to the above variables. Diagnoses of both substance use disorders (SUDs) and psychiatric disorders were made by qualified psychiatrists as per the International Classification of Diseases, 10th revision. Results: Among 307 participants with DD, 100 were in EOS group (onset of SUD before 18 years of age as assessed clinically) and 207 in LOS group. Cannabis as the primary substance was more prevalent in the EOS (30%) than that of the LOS group (12%). Psychotic disorders were more prevalent in the EOS group (41%) followed by mood disorders (30%), while the reverse was true in the LOS group (27.5% and 56.5%, respectively). When compared to the LOS group, the EOS group had higher number of psychiatric admissions, reported higher prevalence of risky sexual behaviors (unprotected sexual intercourse, multiple sexual partners, and history of sexual intercourse with commercial sex workers), showed poorer treatment adherence, and worse outcome regarding both psychiatric disorder and SUD (all differences significant at P < 0.05). Conclusions: DD patients differ significantly based on the age of onset of substance use. These may have therapeutic and management implications.
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Swavlamban Health Insurance scheme for persons with disabilities: An experiential account p. 369
Joseph Wilson James, Chethan Basavarajappa, Thanapal Sivakumar, Ruma Banerjee, Jagadisha Thirthalli
DOI:10.4103/psychiatry.IndianJPsychiatry_77_19  
Context: Out-of-pocket expenditure on health in India is high. Many people including persons with disability (PwD) face catastrophic health expenditure. Health insurance is a promising strategy to overcome this burden. Swavlamban was the first health insurance for PwD which also covered mental illness. We conducted regular camps at the National Institute of Mental Health and Neurosciences (NIMHANS) for enrollment in the scheme. In this study, we present the features of the scheme and the sociodemographic profile of beneficiaries enrolled. Aims: To describe the experience of conducting enrollment camps for the Swavlamban Health Insurance scheme at NIMHANS and the sociodemographic profile of beneficiaries enrolled. Settings and Design: The study comprised all PwD and their family members enrolled in the Swavlamban through the camps conducted at NIMHANS from May 2016 to April 2017. Results: A total of 1248 persons were enrolled, of which 643 were PwD. The beneficiaries (PwD) were predominantly male (69%), with a mean age of 31 years, from Bengaluru (84%), and majority had disability due to mental retardation (43%). Although camps were conducted in mental hospital and publicized among mental health professionals, only 135 persons disabled with mental illness (21% of PwD beneficiaries) were enrolled. Conclusions: Mental health professionals need to take the lead in coordinating with various stakeholders so that the PwD can avail health insurance and other welfare benefits. There is a need to lobby and advocate for making these schemes easily accessible.
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Video-assisted teaching versus traditional didactic lecture in undergraduate psychiatry teaching p. 376
Mona Nongmeikapam, N Sarala, Mohan Reddy, S Ravishankar
DOI:10.4103/psychiatry.IndianJPsychiatry_265_18  
Objectives: The objectives of this study are as follows: (1) To compare video-assisted teaching versus didactic lectures using the pretest and posttest. (2) To compare the feedback on the two teaching methods using a teaching feedback form. Materials and Methods: Two consecutive batches of 22 and 20 students, respectively, of the 3rd year medical undergraduate students posted to the department of psychiatry were included for the study. The first batch underwent video-assisted schizophrenia class and didactic lecture in bipolar disorder (BPAD). A crossover of the topics was done. The students underwent pretest and posttest for each topic using the same set of topic-specific validated multiple choice questions and also filled a prevalidated teaching feedback form for each class. Results: Difference between pre- and post-test scores after all classes was significant, indicating effective gain of knowledge by both methods. Feedback analysis indicated that most students favored video-assisted teaching (total mean feedback score – 61.99) compared to the conventional method (total mean feedback score – 60.58). Increase in mean feedback scores indicates the students' preference. Conclusion: Both didactic and video-assisted lectures were effective in terms of knowledge gained and students' feedback. Using video assistance as a complement to lectures and not to replace the traditional methods is the way forward.
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Burden, coping mechanisms, and quality of life among caregivers of hemodialysis and peritoneal dialysis undergoing and renal transplant patients p. 380
M Nagarathnam, Vishnubotla Sivakumar, S A A Latheef
DOI:10.4103/psychiatry.IndianJPsychiatry_401_18  
Context: Investigations on burden, coping, and quality of life (QOL) in caregivers of hemodialysis (HD) and peritoneal dialysis (PD) undergoing and renal transplant (RT) patients may lead to the well-being of caregivers, and these studies are sparse and nil in Indian context. Aim: This study aims to comparatively evaluate the burden, coping mechanisms, and QOL among caregivers of HD and PD undergoing and RT patients. Setting and Design: Tertiary care hospital, cross-sectional and descriptive study. Subjects and Methods: Burden, coping mechanisms, and QOL in caregivers of HD and PD undergoing and RT patients were investigated using Zarit burden interview, revised ways of coping and short-form 36 in 30 each caregivers of HD and PD undergoing and RT patients. Results: Moderate to severe burden, mild to moderate burden, and no burden were observed in the majority of caregivers of HD and PD undergoing and RT patients. Significantly higher mean burden score in caregivers of HD undergoing than RT patients (P < 0.01); accepting responsibility in caregivers of RT than PD undergoing patients; social functioning in caregivers of HD than PD undergoing patients; and general health in caregivers of RT than HD undergoing patients, was observed. Lower physical component was common in each group, whereas accepting responsibility in HD, self-controlling in PD, and age and escape avoidance in RT were found to be the specific predictors of the burden score. Conclusions: Caregivers of HD and PD undergoing and RT patients have different levels of burden, use different mechanisms to cope, and showed different predictors of burden score.
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Fear of happiness among college students: The role of gender, childhood psychological trauma, and dissociation p. 389
Vedat Sar, Tuğba Türk, Erdinç Öztürk
DOI:10.4103/psychiatry.IndianJPsychiatry_52_17  
Aims: This study aimed to evaluate the fear of happiness among college students and its relationship to gender, childhood psychological trauma, and dissociation. Setting and Design: College students were addressed as study population, and a relational screening method was implemented. Materials and Methods: Among 184 participants, 93 (50.5%) were women. The Fear of Happiness Scale (FHS), the Childhood Trauma Questionnaire (CTQ), and the Dissociative Experiences Scale (DES) were administered to all participants. Statistical Analysis Used: Mann–Whitney-U and Student's t-tests were implemented for comparison of groups. Pearson correlation and stepwise multiple regression analyses were conducted to identify associations between variables. Results: There were no differences on DES, FHS, and CTQ total scores between genders. DES was associated with CTQ total scores in both genders. Women had higher scores than men on childhood emotional abuse and fear of “cheerfulness ends up with bad faith.” Compared to nonmembers, female dissociative taxon members had higher scores on all childhood trauma types except sexual abuse, and on all types of fear of happiness except “good fortune ends up with disaster” which was the only type of fear significantly elevated among male dissociative taxon members. A stepwise regression analysis revealed that depersonalization, childhood emotional neglect, and physical abuse predicted fear of happiness among women which was predicted by absorption among men. Conclusions: There is a relationship between childhood psychological trauma, dissociation, and fear of happiness. Women seem to be more vulnerable in this path of obsessional thinking which affects different realms in male and female genders.
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Differences in depressive and anxiety symptoms between cancer and noncancer patients with psychological distress p. 395
Su Hong Ha, In Hee Shim, Dong Sik Bae
DOI:10.4103/psychiatry.IndianJPsychiatry_342_18  
Background: Cancer patients are particularly vulnerable to psychological problems. The purpose of the present study was to compare differences in psychological difficulties, including depression and anxiety, between cancer patients and noncancer patients. This study assessed the differences in depressive and anxiety symptoms between patients with and without cancer. Materials and Methods: Participants included 219 patients at The Cancer Center, Dongnam Institute of Radiological and Medical Sciences, Busan, Korea, who reported depressive or anxiety symptoms between April 2014 and April 2016. Patients were categorized into cancer and noncancer groups based on medical histories showing a diagnosis of any type of cancer. The Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI) were used to evaluate psychological distress at each patient's first visit. Patients' charts were reviewed for clinical data, including BDI and BAI scores and duration of cancer treatment, and for demographic data such as age and sex. Results: The results showed that patients in the cancer group experienced greater discomfort related to somatic symptoms; higher BDI subscale scores were related to work difficulties, insomnia, loss of appetite, somatic worries (fatigue), and loss of libido compared with patients in the noncancer group. The BAI subscale scores for fear of the worst happening, feeling unsteady, feeling terrified or afraid, a sense of choking, fear of dying, and feeling scared were higher in patients with than in those without cancer. Conclusion: High levels of depressive symptoms related to somatic discomfort and anxiety symptoms related to fear of cancer were associated with considerable psychological distress in patients with cancer diagnosis and treatment.
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Body dissatisfaction and its relation to Big Five personality factors and self-esteem in young adult college women in India p. 400
Geeta Soohinda, Divyanti Mishra, Harshavardhan Sampath, Sanjiba Dutta
DOI:10.4103/psychiatry.IndianJPsychiatry_367_18  
Introduction: Eating disorders are increasingly becoming common among men and women across the world. Body dissatisfaction is found to be one of the prominent risk factors for the development and maintenance of eating disorders. Research suggests that the internalization of culturally unattainable ideals is in fact mediated by self-esteem and personality factors such as high neuroticism, perfectionism, and impulsiveness. Studies on body image concerns in the cultural context of the Indian population are limited. We aimed to study the prevalence of body image dissatisfaction and its association with self-esteem and personality traits among young Indian women. Materials and Methods: Using a cross-sectional design we studied on 555 female college students of North India. Data was collected using self-reported questionnaires: Sociodemographic pro forma, Body Shape Questionnaire (-8C), Rosenberg's Self-Esteem Scale, and Mini-International Personality Item Pool. Results: The mean age of the participants in the study was 22.24 years (±2.75). Twenty-seven percent of the participants had moderate-to-severe body concern. Body shape dissatisfaction significantly correlated with higher body mass index (BMI) (rs = 0.12, P = 0.003) and lower self-esteem (rs = −0.22, P < 0.001). Among the personality traits, only neuroticism (beta = 0.35, P = 0.01) and conscientiousness (beta = 0.29, P = 0.031) significantly predicted body shape dissatisfaction. Conclusion: A significant percentage of young women in this study had a negative body image associated with higher BMI, lower self-esteem, high neuroticism, and high conscientiousness. Thus, consideration of individual variations in personality traits and self-esteem is important understanding body image concerns. This can help in selection of better interventions in the treatment of body image dissatisfaction.
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BRIEF RESEARCH COMMUNICATIONS Top

Psychiatrist facing litigation p. 405
Manohar R Dhadphale
DOI:10.4103/psychiatry.IndianJPsychiatry_316_17  
Malpractice is civil wrong actionable by law. It is true, we have statistically an outside chance of getting sued. Among physicians of all specialties, we have, between 2.6% in North America and 1.3% in Europe, chance of facing malpractice suit. But, that is no comfort for one being sued. Malpractice generally involves, among others, wrongdoing or professional misconduct. It may or may not lead to legal action. I describe two cases of malpractice and its impact on the morale of my mental health team. In one case, the family were seeking compensation by claiming “medical negligence” in a trivial mishap. They had involved the local press to “publicize” their claim. In another case, the grievance arose due to anti-electroconvulsive therapy views of the patient's sister. The families decided not to sue us and accepted decisions of local inquiry. Not much is written on this subject in our country. The cases are almost 20 years old but are still relevant. The author describes the harrowing experience of the team members while the investigation was on. Fortunately, the inquiry panel concluded the proceedings in just 4 weeks. In addition, the author advises how one can prepare the defense. The readers would find informative the case vignettes and strategy to deal with the crisis.
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Prevalence of depressive disorders among head-and-neck cancer patients: A hospital-based, cross-sectional study p. 409
Prateek Yadav, Ravichandra Karkal, Anil Kakunje, Nupur Mahatme, M Akhilesh
DOI:10.4103/psychiatry.IndianJPsychiatry_511_18  
Background: Head-and-neck cancers (HNCs) are associated with significant psychosocial challenges at all stages of illness, which influence the course and outcome of cancer. We aimed to assess the prevalence of depressive disorders among patients with HNC and its sociodemographic and clinical determinants. Materials and Methods: It was a cross-sectional study conducted in the department of oncology of a medical college hospital from South India. A total of 100 adult patients with HNC were recruited over a period of 1 year, after obtaining ethical clearance. Mini International Neuropsychiatric Interview was used to assess for depressive disorders in these patients. Results: We found that 49% of the patients were suffering from major depressive disorder (MDD), 13% of the patients had MDD with melancholic features, and 10% had dysthymia. Functional impairment and surgical treatments were associated with the diagnosis of depressive disorders. Conclusion: Depressive disorders are highly prevalent in HNC and emphasize the need for tailored psycho-oncological and psychotherapeutic interventions.
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VIEWPOINT Top

Improving child and adolescent mental health in India: Status, services, policies, and way forward p. 415
Md Mahbub Hossain, Neetu Purohit
DOI:10.4103/psychiatry.IndianJPsychiatry_217_18  
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LETTERS TO EDITOR Top

Organic mood disorder: Sequelae of small vessel disease p. 420
Shradha Shejekar, Saumitra Shankar Nemlekar, Ashish Srivastava
DOI:10.4103/psychiatry.IndianJPsychiatry_357_18  
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Valproic acid-induced acute pancreatitis p. 421
Ayush Jain, Ijasul Haque, Vandana Tayal, Vandana Roy
DOI:10.4103/psychiatry.IndianJPsychiatry_383_18  
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Comments on “Mental Healthcare Act, 2017, and addiction treatment: Potential pitfalls and trepidations” p. 423
Shahul Ameen
DOI:10.4103/psychiatry.IndianJPsychiatry_206_19  
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Baclofen versus lorazepam for alcohol withdrawal p. 424
Sagar S Garag, Chittaranjan Andrade
DOI:10.4103/psychiatry.IndianJPsychiatry_108_19  
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Four-session cognitive behavioral therapy for the management of obsessive–compulsive disorder using a metaphor for conceptualization: A case report p. 424
Narendra Nath Samantaray, Nilamadhab Kar, Preeti Singh
DOI:10.4103/psychiatry.IndianJPsychiatry_92_19  
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Normal levels of lithium – Can it still be harmful? p. 426
Sagrika Panda, Ritu Singh, Mohan Gurjar, AK Baronia
DOI:10.4103/psychiatry.IndianJPsychiatry_274_18  
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