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2.
JAMA Psychiatry ; 80(8): 768-777, 2023 08 01.
Artículo en Inglés | MEDLINE | ID: mdl-37285133

RESUMEN

Importance: Guided internet-delivered cognitive behavioral therapy (i-CBT) is a low-cost way to address high unmet need for anxiety and depression treatment. Scalability could be increased if some patients were helped as much by self-guided i-CBT as guided i-CBT. Objective: To develop an individualized treatment rule using machine learning methods for guided i-CBT vs self-guided i-CBT based on a rich set of baseline predictors. Design, Setting, and Participants: This prespecified secondary analysis of an assessor-blinded, multisite randomized clinical trial of guided i-CBT, self-guided i-CBT, and treatment as usual included students in Colombia and Mexico who were seeking treatment for anxiety (defined as a 7-item Generalized Anxiety Disorder [GAD-7] score of ≥10) and/or depression (defined as a 9-item Patient Health Questionnaire [PHQ-9] score of ≥10). Study recruitment was from March 1 to October 26, 2021. Initial data analysis was conducted from May 23 to October 26, 2022. Interventions: Participants were randomized to a culturally adapted transdiagnostic i-CBT that was guided (n = 445), self-guided (n = 439), or treatment as usual (n = 435). Main Outcomes and Measures: Remission of anxiety (GAD-7 scores of ≤4) and depression (PHQ-9 scores of ≤4) 3 months after baseline. Results: The study included 1319 participants (mean [SD] age, 21.4 [3.2] years; 1038 women [78.7%]; 725 participants [55.0%] came from Mexico). A total of 1210 participants (91.7%) had significantly higher mean (SE) probabilities of joint remission of anxiety and depression with guided i-CBT (51.8% [3.0%]) than with self-guided i-CBT (37.8% [3.0%]; P = .003) or treatment as usual (40.0% [2.7%]; P = .001). The remaining 109 participants (8.3%) had low mean (SE) probabilities of joint remission of anxiety and depression across all groups (guided i-CBT: 24.5% [9.1%]; P = .007; self-guided i-CBT: 25.4% [8.8%]; P = .004; treatment as usual: 31.0% [9.4%]; P = .001). All participants with baseline anxiety had nonsignificantly higher mean (SE) probabilities of anxiety remission with guided i-CBT (62.7% [5.9%]) than the other 2 groups (self-guided i-CBT: 50.2% [6.2%]; P = .14; treatment as usual: 53.0% [6.0%]; P = .25). A total of 841 of 1177 participants (71.5%) with baseline depression had significantly higher mean (SE) probabilities of depression remission with guided i-CBT (61.5% [3.6%]) than the other 2 groups (self-guided i-CBT: 44.3% [3.7%]; P = .001; treatment as usual: 41.8% [3.2%]; P < .001). The other 336 participants (28.5%) with baseline depression had nonsignificantly higher mean (SE) probabilities of depression remission with self-guided i-CBT (54.4% [6.0%]) than guided i-CBT (39.8% [5.4%]; P = .07). Conclusions and Relevance: Guided i-CBT yielded the highest probabilities of remission of anxiety and depression for most participants; however, these differences were nonsignificant for anxiety. Some participants had the highest probabilities of remission of depression with self-guided i-CBT. Information about this variation could be used to optimize allocation of guided and self-guided i-CBT in resource-constrained settings. Trial Registration: ClinicalTrials.gov Identifier: NCT04780542.


Asunto(s)
Terapia Cognitivo-Conductual , Depresión , Humanos , Femenino , Adulto Joven , Adulto , Depresión/terapia , Universidades , Ansiedad/terapia , Trastornos de Ansiedad/terapia , Trastornos de Ansiedad/psicología , Terapia Cognitivo-Conductual/métodos , Resultado del Tratamiento , Internet
3.
Trials ; 23(1): 450, 2022 Jun 02.
Artículo en Inglés | MEDLINE | ID: mdl-35658942

RESUMEN

BACKGROUND: Major depressive disorder (MDD) and generalized anxiety disorder (GAD) are highly prevalent among university students and predict impaired college performance and later life role functioning. Yet most students do not receive treatment, especially in low-middle-income countries (LMICs). We aim to evaluate the effects of expanding treatment using scalable and inexpensive Internet-delivered transdiagnostic cognitive behavioral therapy (iCBT) among college students with symptoms of MDD and/or GAD in two LMICs in Latin America (Colombia and Mexico) and to investigate the feasibility of creating a precision treatment rule (PTR) to predict for whom iCBT is most effective. METHODS: We will first carry out a multi-site randomized pragmatic clinical trial (N = 1500) of students seeking treatment at student mental health clinics in participating universities or responding to an email offering services. Students on wait lists for clinic services will be randomized to unguided iCBT (33%), guided iCBT (33%), and treatment as usual (TAU) (33%). iCBT will be provided immediately whereas TAU will be whenever a clinic appointment is available. Short-term aggregate effects will be assessed at 90 days and longer-term effects 12 months after randomization. We will use ensemble machine learning to predict heterogeneity of treatment effects of unguided versus guided iCBT versus TAU and develop a precision treatment rule (PTR) to optimize individual student outcome. We will then conduct a second and third trial with separate samples (n = 500 per arm), but with unequal allocation across two arms: 25% will be assigned to the treatment determined to yield optimal outcomes based on the PTR developed in the first trial (PTR for optimal short-term outcomes for Trial 2 and 12-month outcomes for Trial 3), whereas the remaining 75% will be assigned with equal allocation across all three treatment arms. DISCUSSION: By collecting comprehensive baseline characteristics to evaluate heterogeneity of treatment effects, we will provide valuable and innovative information to optimize treatment effects and guide university mental health treatment planning. Such an effort could have enormous public-health implications for the region by increasing the reach of treatment, decreasing unmet need and clinic wait times, and serving as a model of evidence-based intervention planning and implementation. TRIAL STATUS: IRB Approval of Protocol Version 1.0; June 3, 2020. Recruitment began on March 1, 2021. Recruitment is tentatively scheduled to be completed on May 30, 2024. TRIAL REGISTRATION: ClinicalTrials.gov NCT04780542 . First submission date: February 28, 2021.


Asunto(s)
Terapia Cognitivo-Conductual , Trastorno Depresivo Mayor , Ansiedad/terapia , Trastornos de Ansiedad/terapia , Terapia Cognitivo-Conductual/métodos , Depresión/terapia , Humanos , Internet , América Latina , Ensayos Clínicos Pragmáticos como Asunto , Ensayos Clínicos Controlados Aleatorios como Asunto , Estudiantes/psicología , Resultado del Tratamiento , Universidades
4.
J Affect Disord ; 303: 273-285, 2022 04 15.
Artículo en Inglés | MEDLINE | ID: mdl-35176342

RESUMEN

BACKGROUND: Mental health treatment is scarce and little resources are invested in reducing the wide treatment gap that exists in the Americas. The regional barriers are unknown. We describe the barriers for not seeking treatment among those with mental and substance use disorders from six (four low- and middle-income and two high-income) countries from the Americas. Regional socio-demographic and clinical correlates are assessed. METHODS: Respondents (n = 4648) from seven World Mental Health surveys carried out in Argentina, Brazil, Colombia, Mexico, Peru, and the United States, who met diagnostic criteria for a 12-month mental disorder, measured with the Composite International Diagnostic Interview, and who did not access treatment, were asked about treatment need and, among those with need, structural and attitudinal barriers. Country-specific deviations from regional estimates were evaluated through logistic models. RESULTS: In the Americas, 43% of those that did not access treatment did not perceive treatment need, while the rest reported structural and attitudinal barriers. Overall, 27% reported structural barriers, and 95% attitudinal barriers. The most frequent attitudinal barrier was to want to handle it on their own (69.4%). Being female and having higher severity of disorders were significant correlates of greater perceived structural and lower attitudinal barriers, with few country-specific variations. LIMITATIONS: Only six countries in the Americas are represented; the cross-sectional nature of the survey precludes any causal interpretation. CONCLUSIONS: Awareness of disorder or treatment need in various forms is one of the main barriers reported in the Americas and it specially affects persons with severe disorders.


Asunto(s)
Trastornos Mentales , Servicios de Salud Mental , Brasil , Estudios Transversales , Femenino , Accesibilidad a los Servicios de Salud , Encuestas Epidemiológicas , Humanos , Masculino , Trastornos Mentales/diagnóstico , Trastornos Mentales/epidemiología , Trastornos Mentales/terapia , Encuestas y Cuestionarios , Estados Unidos/epidemiología
5.
J Affect Disord ; 303: 168-179, 2022 04 15.
Artículo en Inglés | MEDLINE | ID: mdl-35151675

RESUMEN

OBJECTIVE: To estimate structural and attitudinal reasons for premature discontinuation of mental health treatment, socio-demographic and clinical correlates of treatment dropout due to these reasons, and to test country differences from the overall effect across the region of the Americas. METHODS: World Health Organization-World Mental Health (WMH) surveys were carried out in six countries in the Americas: Argentina, Brazil, Colombia, Mexico, Peru and USA. Among the 1991 participants who met diagnostic criteria (measured with the Composite International Diagnostic Interview (WMHCIDI)) for a mental disorder and were in treatment in the prior 12-months, the 236 (12.2%) who dropped out of treatment before the professional recommended were included. FINDINGS: In all countries, individuals more frequently reported attitudinal (79.2%) rather than structural reasons (30.7%) for dropout. Disorder severity was associated with structural reasons; those with severe disorder (versus mild disorder) had 3.4 (95%CI=1.1-11.1) times the odds of reporting a structural reason. Regarding attitudinal reasons, those with lower income (versus higher income) were less likely to discontinue treatment because of getting better (OR=0.4; 95%CI= 0.2-0.9). Country specific variations were found. LIMITATIONS: Not all countries, or the poorest, in the region were included. Some estimations couldn´t be calculated due to cell size. Causality cannot be assumed. CONCLUSION: Clinicians should in the first sessions address attitudinal factors that may lead to premature termination. Public policies need to consider distribution of services to increase convenience. A more rational use of resources would be to offer brief therapies to individuals most likely to drop out of treatment prematurely.


Asunto(s)
Trastornos Mentales , Servicios de Salud Mental , Brasil , Encuestas Epidemiológicas , Humanos , Trastornos Mentales/epidemiología , Trastornos Mentales/terapia , Encuestas y Cuestionarios
6.
Addiction ; 114(3): 534-552, 2019 03.
Artículo en Inglés | MEDLINE | ID: mdl-30370636

RESUMEN

BACKGROUND AND AIMS: The World Health Organization's (WHO's) proposed International Classification of Diseases, 11th edition (ICD-11) includes several major revisions to substance use disorder (SUD) diagnoses. It is essential to ensure the consistency of within-subject diagnostic findings throughout countries, languages and cultures. To date, agreement analyses between different SUD diagnostic systems have largely been based in high-income countries and clinical samples rather than general population samples. We aimed to evaluate the prevalence of, and concordance between diagnoses using the ICD-11, The WHO's ICD 10th edition (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders, 4th and 5th editions (DSM-IV, DSM-5); the prevalence of disaggregated ICD-10 and ICD-11 symptoms; and variation in clinical features across diagnostic groups. DESIGN: Cross-sectional household surveys. SETTING: Representative surveys of the general population in 10 countries (Argentina, Australia, Brazil, Colombia, Iraq, Northern Ireland, Poland, Portugal, Romania and Spain) of the World Mental Health Survey Initiative. PARTICIPANTS: Questions about SUDs were asked of 12 182 regular alcohol users and 1788 cannabis users. MEASUREMENTS: Each survey used the World Mental Health Survey Initiative version of the WHO Composite International Diagnostic Interview version 3.0 (WMH-CIDI). FINDINGS: Among regular alcohol users, prevalence (95% confidence interval) of life-time ICD-11 alcohol harmful use and dependence were 21.6% (20.5-22.6%) and 7.0% (6.4-7.7%), respectively. Among cannabis users, 9.3% (7.4-11.1%) met criteria for ICD-11 harmful use and 3.2% (2.3-4.0%) for dependence. For both substances, all comparisons of ICD-11 with ICD-10 and DSM-IV showed excellent concordance (all κ ≥ 0.9). Concordance between ICD-11 and DSM-5 ranged from good (for SUD and comparisons of dependence and severe SUD) to poor (for comparisons of harmful use and mild SUD). Very low endorsement rates were observed for new ICD-11 feature for harmful use ('harm to others'). Minimal variation in clinical features was observed across diagnostic systems. CONCLUSIONS: The World Health Organization's proposed International Classification of Diseases, 11th edition (ICD-11) classifications for substance use disorder diagnoses are highly consistent with the ICD 10th edition and the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Concordance between ICD-11 and the DSM 5th edition (DSM-5) varies, due largely to low levels of agreement for the ICD harmful use and DSM-5 mild use disorder. Diagnostic validity of self-reported 'harm to others' is questionable.


Asunto(s)
Alcoholismo/diagnóstico , Abuso de Marihuana/diagnóstico , Alcoholismo/clasificación , Alcoholismo/epidemiología , Argentina/epidemiología , Australia/epidemiología , Brasil/epidemiología , Colombia/epidemiología , Estudios Transversales , Manual Diagnóstico y Estadístico de los Trastornos Mentales , Humanos , Clasificación Internacional de Enfermedades , Irak/epidemiología , Abuso de Marihuana/clasificación , Abuso de Marihuana/epidemiología , Irlanda del Norte/epidemiología , Polonia/epidemiología , Portugal/epidemiología , Rumanía/epidemiología , España/epidemiología , Trastornos Relacionados con Sustancias/clasificación , Trastornos Relacionados con Sustancias/diagnóstico , Trastornos Relacionados con Sustancias/epidemiología , Encuestas y Cuestionarios , Organización Mundial de la Salud
7.
Depress Anxiety ; 34(4): 315-326, 2017 04.
Artículo en Inglés | MEDLINE | ID: mdl-27921352

RESUMEN

BACKGROUND: Unexpected death of a loved one (UD) is the most commonly reported traumatic experience in cross-national surveys. However, much remains to be learned about posttraumatic stress disorder (PTSD) after this experience. The WHO World Mental Health (WMH) survey initiative provides a unique opportunity to address these issues. METHODS: Data from 19 WMH surveys (n = 78,023; 70.1% weighted response rate) were collated. Potential predictors of PTSD (respondent sociodemographics, characteristics of the death, history of prior trauma exposure, history of prior mental disorders) after a representative sample of UDs were examined using logistic regression. Simulation was used to estimate overall model strength in targeting individuals at highest PTSD risk. RESULTS: PTSD prevalence after UD averaged 5.2% across surveys and did not differ significantly between high-income and low-middle income countries. Significant multivariate predictors included the deceased being a spouse or child, the respondent being female and believing they could have done something to prevent the death, prior trauma exposure, and history of prior mental disorders. The final model was strongly predictive of PTSD, with the 5% of respondents having highest estimated risk including 30.6% of all cases of PTSD. Positive predictive value (i.e., the proportion of high-risk individuals who actually developed PTSD) among the 5% of respondents with highest predicted risk was 25.3%. CONCLUSIONS: The high prevalence and meaningful risk of PTSD make UD a major public health issue. This study provides novel insights into predictors of PTSD after this experience and suggests that screening assessments might be useful in identifying high-risk individuals for preventive interventions.


Asunto(s)
Actitud Frente a la Muerte , Muerte , Encuestas Epidemiológicas/estadística & datos numéricos , Acontecimientos que Cambian la Vida , Trastornos por Estrés Postraumático/epidemiología , Trastornos por Estrés Postraumático/psicología , Adolescente , Adulto , Asia/epidemiología , Niño , Preescolar , Europa (Continente)/epidemiología , Femenino , Humanos , Lactante , Modelos Logísticos , Masculino , Prevalencia , Riesgo , Factores Socioeconómicos , Sudáfrica/epidemiología , América del Sur/epidemiología , Estados Unidos/epidemiología , Adulto Joven
8.
Braz J Psychiatry ; 35(2): 115-25, 2013.
Artículo en Inglés | MEDLINE | ID: mdl-23904015

RESUMEN

OBJECTIVE: To assess prevalence and correlates of family caregiver burdens associated with mental and physical conditions worldwide. METHODS: Cross-sectional community surveys asked 43,732 adults residing in 19 countries of the WHO World Mental Health (WMH) Surveys about chronic physical and mental health conditions of first-degree relatives and associated objective (time, financial) and subjective (distress, embarrassment) burdens. Magnitudes and associations of burden are examined by kinship status and family health problem; population-level estimates are provided. RESULTS: Among the 18.9-40.3% of respondents in high, upper-middle, and low/lower-middle income countries with first-degree relatives having serious health problems, 39.0-39.6% reported burden. Among those, 22.9-31.1% devoted time, 10.6-18.8% had financial burden, 23.3-27.1% reported psychological distress, and 6.0-17.2% embarrassment. Mean caregiving hours/week was 12.9-16.5 (83.7-147.9 hours/week/100 people aged 18+). Mean financial burden was 15.1% of median family income in high, 32.2% in upper-middle, and 44.1% in low/lower-middle income countries. A higher burden was reported by women than men, and for care of parents, spouses, and children than siblings. CONCLUSIONS: The uncompensated labor of family caregivers is associated with substantial objective and subjective burden worldwide. Given the growing public health importance of the family caregiving system, it is vital to develop effective interventions that support family caregivers.


Asunto(s)
Cuidadores/psicología , Costo de Enfermedad , Personas con Discapacidad/estadística & datos numéricos , Familia/psicología , Trastornos Mentales/enfermería , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Estudios Transversales , Femenino , Humanos , Masculino , Trastornos Mentales/epidemiología , Salud Mental/estadística & datos numéricos , Persona de Mediana Edad , Medición de Riesgo , Factores de Tiempo , Organización Mundial de la Salud , Adulto Joven
9.
Braz. J. Psychiatry (São Paulo, 1999, Impr.) ; Braz. J. Psychiatry (São Paulo, 1999, Impr.);35(2): 115-125, April-June 2013. tab
Artículo en Inglés | LILACS | ID: lil-680888

RESUMEN

Objective: To assess prevalence and correlates of family caregiver burdens associated with mental and physical conditions worldwide. Methods: Cross-sectional community surveys asked 43,732 adults residing in 19 countries of the WHO World Mental Health (WMH) Surveys about chronic physical and mental health conditions of first-degree relatives and associated objective (time, financial) and subjective (distress, embarrassment) burdens. Magnitudes and associations of burden are examined by kinship status and family health problem; population-level estimates are provided. Results: Among the 18.9-40.3% of respondents in high, upper-middle, and low/lower-middle income countries with first-degree relatives having serious health problems, 39.0-39.6% reported burden. Among those, 22.9-31.1% devoted time, 10.6-18.8% had financial burden, 23.3-27.1% reported psychological distress, and 6.0-17.2% embarrassment. Mean caregiving hours/week was 12.9-16.5 (83.7-147.9 hours/week/100 people aged 18+). Mean financial burden was 15.1% of median family income in high, 32.2% in upper-middle, and 44.1% in low/lower-middle income countries. A higher burden was reported by women than men, and for care of parents, spouses, and children than siblings. Conclusions: The uncompensated labor of family caregivers is associated with substantial objective and subjective burden worldwide. Given the growing public health importance of the family caregiving system, it is vital to develop effective interventions that support family caregivers. .


Asunto(s)
Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Adulto Joven , Cuidadores/psicología , Costo de Enfermedad , Personas con Discapacidad/estadística & datos numéricos , Familia/psicología , Trastornos Mentales/enfermería , Estudios Transversales , Trastornos Mentales/epidemiología , Salud Mental/estadística & datos numéricos , Medición de Riesgo , Factores de Tiempo , Organización Mundial de la Salud
10.
J Clin Psychiatry ; 71(12): 1617-28, 2010 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-20816034

RESUMEN

OBJECTIVE: Although suicide is a leading cause of death worldwide, clinicians and researchers lack a data-driven method to assess the risk of suicide attempts. This study reports the results of an analysis of a large cross-national epidemiologic survey database that estimates the 12-month prevalence of suicidal behaviors, identifies risk factors for suicide attempts, and combines these factors to create a risk index for 12-month suicide attempts separately for developed and developing countries. METHOD: Data come from the World Health Organization (WHO) World Mental Health (WMH) Surveys (conducted 2001-2007), in which 108,705 adults from 21 countries were interviewed using the WHO Composite International Diagnostic Interview. The survey assessed suicidal behaviors and potential risk factors across multiple domains, including sociodemographic characteristics, parent psychopathology, childhood adversities, DSM-IV disorders, and history of suicidal behavior. RESULTS: Twelve-month prevalence estimates of suicide ideation, plans, and attempts are 2.0%, 0.6%, and 0.3%, respectively, for developed countries and 2.1%, 0.7%, and 0.4%, respectively, for developing countries. Risk factors for suicidal behaviors in both developed and developing countries include female sex, younger age, lower education and income, unmarried status, unemployment, parent psychopathology, childhood adversities, and presence of diverse 12-month DSM-IV mental disorders. Combining risk factors from multiple domains produced risk indices that accurately predicted 12-month suicide attempts in both developed and developing countries (area under the receiver operating characteristic curve = 0.74-0.80). CONCLUSIONS: Suicidal behaviors occur at similar rates in both developed and developing countries. Risk indices assessing multiple domains can predict suicide attempts with fairly good accuracy and may be useful in aiding clinicians in the prediction of these behaviors.


Asunto(s)
Encuestas Epidemiológicas/métodos , Salud Mental/estadística & datos numéricos , Intento de Suicidio/estadística & datos numéricos , Organización Mundial de la Salud/organización & administración , Adulto , Factores de Edad , Anciano , Comorbilidad , Países Desarrollados/estadística & datos numéricos , Países en Desarrollo/estadística & datos numéricos , Manual Diagnóstico y Estadístico de los Trastornos Mentales , Estudios Epidemiológicos , Femenino , Salud Global , Encuestas Epidemiológicas/estadística & datos numéricos , Humanos , Cooperación Internacional , Masculino , Trastornos Mentales/diagnóstico , Trastornos Mentales/epidemiología , Persona de Mediana Edad , Padres/psicología , Prevalencia , Factores de Riesgo , Factores Sexuales , Clase Social , Ideación Suicida
11.
Biol Psychiatry ; 65(1): 46-54, 2009 Jan 01.
Artículo en Inglés | MEDLINE | ID: mdl-19006789

RESUMEN

BACKGROUND: Although it is known that childhood attention-deficit/hyperactivity disorder (ADHD) often persists into adulthood, childhood predictors of this persistence have not been widely studied. METHODS: Childhood history of ADHD and adult ADHD were assessed in 10 countries in the World Health Organization World Mental Health Surveys. Logistic regression analysis was used to study associations of retrospectively reported childhood risk factors with adult persistence among the 629 adult respondents with childhood ADHD. Risk factors included age; sex; childhood ADHD symptom profiles, severity, and treatment; comorbid child/adolescent DSM-IV disorders; childhood family adversities; and child/adolescent exposure to traumatic events. RESULTS: An average of 50% of children with ADHD (range: 32.8%-84.1% across countries) continued to meet DSM-IV criteria for ADHD as adults. Persistence was strongly related to childhood ADHD symptom profile (highest persistence associated with the attentional plus impulsive-hyperactive type, odds ratio [OR]=12.4, compared with the lowest associated with the impulsive-hyperactive type), symptom severity (OR=2.0), comorbid major depressive disorder (MDD; OR=2.2), high comorbidity (>or=3 child/adolescent disorders in addition to ADHD; OR=1.7), paternal (but not maternal) anxiety mood disorder (OR=2.4), and parental antisocial personality disorder (OR=2.2). A multivariate risk profile of these variables significantly predicts persistence of ADHD into adulthood (area under the receiving operator characteristic curve=.76). CONCLUSIONS: A substantial proportion of children with ADHD continue to meet full criteria for ADHD as adults. A multivariate risk index comprising variables that can be assessed in adolescence predicts persistence with good accuracy.


Asunto(s)
Trastorno por Déficit de Atención con Hiperactividad/epidemiología , Adolescente , Adulto , Niño , Comorbilidad , Recolección de Datos , Femenino , Predicción , Humanos , Modelos Logísticos , Masculino , Escalas de Valoración Psiquiátrica , Estudios Retrospectivos , Factores de Riesgo , Organización Mundial de la Salud
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