I made a film from my bed to prove my illness is real

BBC news article, 9 Nov 2017: I made a film from my bed to prove my illness is real

Five years ago, Jennifer Brea was struck down by ME (Myalgic Encephalomyelitis), and found herself bed-bound, a prisoner in her own body. Now, she has invited the world on an intimate journey into a condition that some deny even exists, interviewing fellow patients from all over the world – from her sickbed. She spoke to the BBC’s Natasha Lipman.

As the opening credits roll on the documentary, Unrest, we see filmmaker Jennifer Brea lying on the floor of her bedroom, eyes glazed over, as she stares apparently peacefully at the camera. Then, with arms shaking, gasping for breath, she tries to pull herself up, managing only a few inches before she collapses back on the floor. Eventually she is able to crawl slowly to her bed, before dropping the camera, collapsing with relief and fatigue.

Episodes like this initially came as a shock for Brea. Seemingly out of nowhere, she would suddenly lose all muscle force, unable to move her body, or even lift her head. She struggled to get words out, let alone form sentences, and even the smallest exertion would have knock-on effects that lasted for days, weeks, or even months.

“I’d never been sick before and so I had this sense of abundance of health and body and life. I had never really heard about ME or people becoming ill in their 20s – it just wasn’t a part of my awareness. So I never imagined that something like this could happen to me.”

While studying for a PhD in Political Economy and Statistics at Harvard, she met fellow student, Omar Wasow, an internet analyst and entrepreneur who once taught Oprah Winfrey how to surf the net. They married in 2012. Home videos show the life Brea and Wasow led before she became sick – travelling the world, scuba diving, candlelit dinners with friends – a perfect vision of a carefree young couple in love.

Shortly before their wedding, they both contracted a virus, coming down with a high fever. Wasow recovered completely, but afterwards Brea remained plagued by strange symptoms. Whenever she got a sore throat or a cold she would have dizzy spells and crash out for days at a time. She suffered from insomnia, and memory loss – symptoms she now recognises as a mild form of ME. They all seemed to get worse after exercise.

“Omar and I used to always do this bike ride along the river – six miles out, six miles back -and I noticed that while I could make it six miles out, then I had to call a taxi to get back home. Or I would go skiing with my family, and suddenly feel my legs giving out,” she says.

“I didn’t know why.”

She suspected there might be something wrong with her immune system and went to her doctor, but the lab tests always came back normal.

“I was told that either I wasn’t really sick or that maybe I was just depressed or that it was all in my head,” she says.

Brea was eventually diagnosed with Conversion Disorder, a mental condition with unexplained physical symptoms – formerly known as hysteria – and told it was due to a childhood trauma she couldn’t even remember.

It wasn’t until she showed doctors the disturbing footage of her symptoms from the video diary she’d been recording on her phone that she was finally taken seriously and sent for a battery of physical tests.

“I still had hope that I just had a rare disease – that if I could just get to the right specialist they would figure out what was wrong with me,” says Brea.

It turned out that what she had is actually very common – ME, a condition that affects up to 17 million people worldwide, according to some estimates. Now her illness had a name, but she discovered that there was very little medical research into, much controversy over treatments, and no cure.

“That was something that I never imagined could happen. I always thought that medicine would be there to help me,” says Brea. “In some ways getting the diagnosis was a bit of a relief but it also gave me this sense of: ‘Oh my gosh, what I have to deal with is actually much more complicated than I imagined.'”

What is ME?

  • ME – also called Chronic Fatigue Syndrome – is a medical condition characterised by profound and disabling fatigue
  • Symptoms include: loss of muscle power, debilitating pain, difficulty sleeping and cognitive dysfunction affecting memory and concentration
  • The cause of ME is unknown, but many patients contract it after a viral infection
  • Women are four times as likely to have ME than men
  • The NHS guidelines on ME treatment are currently being revised

Read more about Jen and Omar, the film and ME

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Heart rate variability (HRV) an underused ME/CFS/FM management tool

Health rising treatment resources blog post, by Karmin, 24 Oct 2017:

Karmin continues her series on heart rate variability (HRV) testing. Everyone concerned with pacing – a subject everyone with ME/CFS/FM has reason to be concerned with – will find vital information in Karmin’s blogs. Among the highlights:

  • Tracking your heart rate is a good idea, but tracking your HRV can provide a deeper, more informative cut particularly with regard to cognitive activities
  • As others (Dr. Pocinki, Staci Stevens, Dan Neuffer) have asserted, Karmin’s data suggests there’s more to the autonomic nervous system problems in ME/CFS/FM that an over-active fight or flight system.
  • How to watch out for injurious parasympathetic nervous system spikes.
  • How slow improvements with HRV are better than rapid shifts.
  • Why exercises like yoga may be better for ME/CFS/FM patients than isometric exercises.

Heart Rate Variability (HRV) – An Under-Utilized ME/CFS/FM Management Tool: PART II – Surveying the Landscape by Karmin

This series of blogs is meant as a beginner’s guide to using Heart Rate Variability (HRV) to manage ME/CFS. In my last blog I explained how HRV measurement can provide a window into the function of the Autonomic Nervous System (ANS) and I detailed how to begin measuring HRV.

See “Your Crash in a Graph: How Heart Rate Variability Testing Could Help You Improve Your Health”

Once familiar with measuring HRV, you can begin using it to survey your ANS landscape. I have found it to be an eye opening experience!

Data Collection

It is important to first think about what data you want to collect.

In my initial enthusiasm for HRV, I was collecting lots of data whilst doing all sorts of activities. All that measuring did give me interesting information, but for the most part it didn’t change how I managed my illness. As well – being at the severe end of the ME/CFS spectrum – I felt I needed to get the most value out of my data for the least amount of work.

There were other factors I also considered. There is a tendency in ME/CFS for the ANS to over-respond or over-correct following an activity. For example, when the Parasympathetic Nervous System (PNS) is activated, there is sometimes a reflex Sympathetic Nervous System (SNS) response that follows, and sometimes even further PNS and SNS responses after that. Recording HRV during an activity does not tell me what ultimate effect that activity will have.

For more on this see Dysfunction Junction by Dr. Alan Pocinki

The Key Data Point – Morning Resting HRV

HRV’s strength is as an indicator of recovery. And it is morning HRV that gives that information. (In my opinion, heart rate monitoring is more suited to monitoring during activity). I, therefore, believe that the most useful HRV data comes from assessing the carryover effect that various activities and treatments have on my next morning HRV numbers. So my focus is on measuring recovery by tracking morning resting HRV. Using HRV in this way brings me huge benefits for a tiny amount of time and effort.

 

Read more for a discussion of how to use an app with illustrations from:

  • (iOS) LogsAll “Track Anything” app
  • Elite
  • SweetBeat

 

Tips:

  • Don’t always test the same treatments together.
  • Always take your readings at about the same time each morning
  • use a good quality chest strap
  • check signal quality in your HRV apps, and
  • regularly replace the batteries in your equipment.

Cognitive Pacing

I find that one big advantage that HRV monitoring has over Heart Rate monitoring is that for me it better identifies problems with non-physical overdoing. My heart rate is not usually adversely affected by cognitive exertion but the adverse effects do show up in my next morning HRV. A useful tool!

Graded Exercise Therapy (GET)

I believe HRV monitoring may be a great defense against PACE-style Graded Exercise Therapy (GET) – or at least a way of determining whether GET is helping or harming a particular patient. Trying to argue that a patient should continue a particular GET programme when their HRV numbers are clearly being adversely affected surely leaves a GET proponent without a leg to stand on. I only wish I had known about HRV tracking when I was prescribed GET years ago!

Yoga

I have always felt there was something different about yoga that makes it more tolerable (and beneficial) to ME/CFS patients. It feels like I am working with my body, not against it. Yoga was the last exercise I was able to do as I slid down to becoming bedridden, and it has been the first exercise I have been able to add back in.

At the beginning of this Blog, I explained that I no longer monitor HRV during activities, but rather use morning HRV as my foundation for determining an appropriate and sustainable level of daily activity. However, to finish, I am going to share the results of an interesting experiment I did some years ago, during an exercise activity.

I divided a very short exercise session into two halves. In the first half I did a low level lying yoga pose, then in the second half I did a low level lying isometric type exercise of similar difficulty. I was blown away by the resultant graph:

SweetBeat graph: First half showing sympathetic/parasympathetic balance whilst doing low level yoga, second half showing sympathetic activation whilst doing a low level isometric exercise

Despite the fact that my heart rate was well within the anaerobic threshold during both exercises, the graph shows how much more the isometric exercise activated my sympathetic nervous system. Any wonder it feels like there’s something different about yoga!

Importantly, not only does yoga give better autonomic balance during the activity, but for me the positive effects also carry over to the next day – as evidenced by improved next morning HF (parasympathetic) numbers.

I find this graph especially interesting in light of Georgetown University research showing that increased SNS activation with exercise can temporarily cause POTS

Heart Rate Monitors

Many heart rate monitors are available.

  • Karmin uses the Wahoo TICKR Heart Rate Monitor for iPhone & Android which has center front clasp which makes it much easier for someone with ME/CFS to put on!
  • The Polar H7 Bluetooth Heart Rate Sensor and Fitness Tracker has been considered the gold standard but her frame was too small.

More Resources

Part I: Check out Part ! – “Your Crash in a Graph: How Heart Rate Variability Testing Could Help You Improve Your Health” – of Karmin’s HRV blog series for ME/CFS and FM for the basics of HRV testing and the apps she uses:

Pacing and Activity Management – See Health Rising’s Pacing, Exercise and Activity Management Resource Section

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Hyperactive brain in CFS – neurometabolites in anterior cingulate cortex

Research abstract:

Neurometabolites in anterior cingulate cortex in chronic fatigue syndrome: a magnetic resonance spectroscopy study at 7 Tesla, by Chi Chen, [Master’s Thesis, Oxford University Sep 2017]

Background:
Chronic fatigue syndrome (CFS) is a disorder characterized by prolonged physical and mental fatigue that cannot be explained by another established medical diagnosis. The anterior cingulate cortex (ACC) and putamen are two regions involved in frontal-striatal neural circuitry, which may be related to the pathophysiology of CFS. The aim of this study was to investigate the concentrations of neurometabolites, including glutamate, gamma-aminobutyric acid (GABA) and glutathione, in  the ACC and putamen, using magnetic resonance spectroscopy (MRS) at 7 Tesla (7T). In addition, this study also aimed to evaluate resting-state functional connectivity in CFS with functional magnetic resonance imaging (fMRI).

Methods
This study involved 12 patients who met the Oxford criteria for CFS and 25 healthy controls. Participants rated themselves on the Chalder Fatigue Questionnaire (CFQ) and the Beck Depression Inventory (BDI). All participants had a single proton (1H) MRS and resting-state fMRI scan with a 7T Siemens MAGNETOM scanner (Siemens, Erlangen, Germany) with a Nova Medical 32 channel receive array head coil. Spectra were measured
from voxels in the ACC (20x20x20 mm), putamen (10x16x20 mm) and occipital cortex (20x20x20 mm). Spectra were analysed with LCModel to obtain absolute concentrations of the neurochemicals. Differences in functional connectivity between CFS and healthy participants were tested using multivariate exploratory linear optimized decomposition into independent components (MELODIC) and dual regression.

Results
Concentrations of putamen glutamate and glutamate+glutamine (Glx) were increased in CFS while that of ACC GABA was decreased. Putamen Glx and ACC glutamine were negatively associated with the severity of self-reported fatigue. There were main effects of CFS diagnosis on glutathione (GSH) and total creatine, indicating decreases of these
neurometabolites in all the regions studied in CFS patients. In addition, the CFS patients demonstrated elevated functional connectivity between the default mode network and right supracalcarine cortex, precuneus cortex and dorsolateral prefrontal cortex.

Conclusions
The increased putamen glutamate, decreased ACC GABA and elevated resting state functional connectivity of the default mode network suggest a hyperactive brain status in CFS. The global decrease of GSH and total creatine also suggest that CFS patients may have an abnormal bioenergetic status with higher oxidative stress.

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Blood cells in CFS are drained of energy

New Scientist article, by Andy Coghlan, 3 Nov 2017: Blood cells in chronic fatigue syndrome are drained of energy

Blood cells in people with CFS seem as listless as it can make people feel

Thirteen years ago, Cara Tomas was rendered bedbound with chronic fatigue syndrome. It came on suddenly, she says, without warning signs. Even now she has good days and bad days due to the lingering effects of the disease. “A lot of people dismiss it as a psychological disease, which is a big frustration,” she says.

Tomas knows more about CFS than most. A PhD student at Newcastle University in the UK, she has just published a paper demonstrating that white blood cells in people with the disease are as listless as the people themselves often feel. “Now we’ve shown there’s a physiological difference, it could explain the whole-body fatigue shown by patients,” she says.

The finding adds to mounting evidence that the disorder has a biological explanation, and raises the prospects for new treatments and diagnostic tests.

For many years, arguments have raged over whether CFS — also known as myalgic encephalomyelitis, or ME — has a physiological or psychological basis. But the latest research comparing samples of peripheral blood mononuclear cells (PBMCs) from 52 people with the condition and 35 without has reinforced the case for a biological explanation.

Less mighty mitochondria
Across almost all measures of energy capacity, the cells from people with CFS were weaker compared with their healthy counterparts. If other cells are equally compromised, it could explain why people with the condition are often bed- or wheelchair-bound for months, and struggle with even modest physical exertion.

Read more

See also: Science alert blog post, by Mike McRae, 7 Nov 2017: People With Chronic Fatigue Syndrome Are Exhausted at a Cellular Level, Study Shows

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Norwegian Rituximab studies update

Helse Bergen blog post, 29 Sep 29017: RituxME

B-lymphocyte depletion using the anti-CD20 antibody rituximab (Mabthera®) in Myalgic Encephalopathy/Chronic Fatigue Syndrome (“RituxME”)

​RituxME is a multicentre study conducted in five study centres in Norway: the Oncology Department at Haukeland University Hospital, the ME/CFS Centre at Oslo University Hospital (Aker), the Dept of Medicine at Notodden Hospital, the Dept. of Pain and Complex Disorders at St. Olav’s Hospital in Trondheim, and the Division of Rehabilitation Services at the University Hospital of North Norway in Tromsø.

The purpose of the study is to confirm or disprove the results from two smaller phase II studies, which have indicated improvement in symptoms in a subgroup of ME patients after rituximab treatment.

The study is randomized, double-blind and placebo controlled. This means that out of 152 participants, half will receive treatments with rituximab and the other half will be treated with placebo (saline). The treatments are allocated at random, and neither patient nor doctor is informed of which intervention group the patient is allocated to.

All participants receive six intravenous treatments during one year, followed by one year of regular consultations and blood tests. The participants complete examinations and tests before and after treatment, and they submit regular reports on any changes in symptoms and physical function.

The clinical study also encompasses three substudies:

  • Endothelial function in ME/CFS – at Haukeland University Hospital and Notodden Hospital
  • Ergospirometry in ME/CFS – at Haukeland University Hospital, Notodden Hospital and Oslo Universitety Hospital.
  • Irritable Bowel Syndrome and functional dyspepsia in ME/CFS – at Haukeland University Hospital.

Status, RituxME
All patient treatment and follow-up has been completed according to schedule in September 2017. The placebo and rituximab groups will be revealed to the scientists in October, and all participants will receive a letter informing them of which treatment group they were allocated to. We will then start working on the analysis of results, and expect to publish the results of the study in a medical journal during the first half of 2018.

Note: Senior Consultant Øystein Fluge and Professor Olav Mella supervise the ME/CFS research group at the Dept. of Oncology and Medical Physics at Haukeland University Hospital.

Read more about ME/CFS Research at Haukeland Hospital

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Unrest film now available for download!

Jennifer Brea’s film Unrest is now available for download.

It will also be available on DVD in December.

Proceeds from the sale of Unrest will be reinvested into the Time For Unrest campaign, helping to bring the film to medical schools, policymakers, and research centres around the world.

Help bring Unrest to more people and raise awareness of ME:

  • buy via iTunes and get Unrest to the top of the iTunes chart! This is one of the best ways to make sure the film gets on the radar of millions of new viewers
  • talk to WAMES about helping to organise a screening in your area #TimeForUnrestWales campaign
  • share the order link and trailer on social media with the hashtag, #TimeforUnrest to join the conversation.

Jennifer Brea talks about her film Unrest in the UK media

Moving. Astonishing.” – Mark Kermode for BBC Radio 5

Unrest is … clever, fascinating, heartwrenching, and very frustrating. This portrait of a couple coping through extreme adversity … will chew you up and spit you backout again.” – The Upcoming

Bracingly inventive and moving.” – The Observer

Important for so many reasons.” – Cosmopolitan UK

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Treating autism and ME/CFS: could one drug help both?

Open Medicine Foundation blog post, by Cort Johnson, 19 October 2017: Treating autism and ME/CFS: could one drug help both?

Autism is one of the most difficult conditions to treat. A neurodevelopmental disorder that typically strikes before the age of two, about a dozen different areas of the brain are affected.

Autism is characterized by social withdrawal, problems with both verbal and non-verbal communications and repetitive behaviors.  Autistic infants tend to smile less and have less eye contact with others than normal, have trouble in social situations, and are less verbal. The prognosis for autistic children is bleak with one study finding that only 4% ever achieve full independence.

Autism Spectrum Disorder (ASD) and ME/CFS
ASD is not chronic fatigue syndrome (ME/CFS) but some similarities exist. Both diseases affect cognition and sensory processing, cause problems with stimuli, cause significant social withdrawal, and are associated with increased levels of oxidative stress, reduced glutathione levels, and a Th2 immune response shift.

According to Dr. Naviaux, “ASD and ME/CFS are on the same biological spectrum.”  Dr. Naviaux has encountered teenagers with ASD who develop ME/CFS, and adults with ME/CFS who develop autism-like symptoms of mutism, social withdrawal, sensory hypersensitivities, and OCD-like symptoms.

Both, he believes, are caused by a failure of the cell danger response (CDR) to shut down normally after a chemical or biological injury has been healed or cleared. Both disorders lead to abnormalities in metabolism that he has characterized using a laboratory tool called mass spectrometry and metabolomics.  (The similarities in metabolism are illustrated in Figure 1.)

Some of the abnormalities shared by both disorders include disturbances in purines, sphingolipids (including sphingomyelins and ceramides), phospholipids, and the microbiome.  Depending on whether a person is still actively fighting a perceived threat like a virus, bacterium, or toxin, or whether they are trying to heal after the exposure, these pathways can be increased or decreased compared to normal.  The take-home message is that these are precisely the same pathways the cell uses normally for fight infection and recovery from injuries.

Read more

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Cellular bioenergetics is impaired in patients with CFS

Research abstract:

Cellular bioenergetics is impaired in patients with chronic fatigue syndrome, by Cara Tomas, Audrey Brown, Victoria Strassheim, Joanna Elson, Julia Newton, Philip Manning in PLOSone [Published: October 24, 2017]

Chronic fatigue syndrome (CFS) is a highly debilitating disease of unknown aetiology. Abnormalities in bioenergetic function have been cited as one possible cause for CFS. Preliminary studies were performed to investigate cellular bioenergetic abnormalities in CFS patients. A series of assays were conducted using peripheral blood mononuclear cells (PBMCs) from CFS patients and healthy controls.

These experiments investigated cellular patterns in oxidative phosphorylation (OXPHOS) and glycolysis. Results showed consistently lower measures of OXPHOS parameters in PBMCs taken from CFS patients compared with healthy controls.

Seven key parameters of OXPHOS were calculated: basal respiration, ATP production, proton leak, maximal respiration, reserve capacity, non-mitochondrial respiration, and coupling efficiency.

While many of the parameters differed between the CFS and control cohorts, maximal respiration was determined to be the key parameter in mitochondrial function to differ between CFS and control PBMCs due to the consistency of its impairment in CFS patients found throughout the study (p≤0.003).

The lower maximal respiration in CFS PBMCs suggests that when the cells experience physiological stress they are less able to elevate their respiration rate to compensate for the increase in stress and are unable to fulfil cellular energy demands. The metabolic differences discovered highlight the inability of CFS patient PBMCs to fulfil cellular energetic demands both under basal conditions and when mitochondria are stressed during periods of high metabolic demand.

Health rising: Cellular Energy Production Takes Big Hit in Chronic Fatigue Syndrome (ME/CFS) Study

New Scientist: Blood cells in chronic fatigue syndrome are drained of energy

Science alert blog post, by Mike McRae, 7 Nov 2017: People With Chronic Fatigue Syndrome Are Exhausted at a Cellular Level, Study Shows

ME Association: We hear from Cara Tomas about her about her recent study on cellular bioenergetics deficiencies in ME/CFS

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Grey and white brain matter differences in CFS

Research abstract:

Grey and white matter differences in Chronic Fatigue Syndrome – a voxel-based morphometry study, by Andreas Finkelmeyer, Jiabao He, Laura Maclachlan, Stuart Watson, Peter Gallagher, Julia L. Newton, Andrew M. Blamire in NeuroImage: Clinical, Volume 17, 2018, Pages 24-30 [Preprint Available online 28 September 2017]

Objective:
Investigate global and regional grey and white matter volumes in patients with Chronic Fatigue Syndrome (CFS) using magnetic resonance imaging (MRI) and recent voxel-based morphometry (VBM) methods.

Methods:
Forty-two patients with CFS and thirty healthy volunteers were scanned on a 3-Tesla MRI scanner. Anatomical MRI scans were segmented, normalized and submitted to a VBM analysis using randomisation methods. Group differences were identified in overall segment volumes and voxel-wise in spatially normalized grey matter (GM) and white matter (WM) segments.

Results:
Accounting for total intracranial volume, patients had larger GM volume and lower WM volume. The voxel-wise analysis showed increased GM volume in several structures including the amygdala and insula in the patient group. Reductions in WM volume in the patient group were seen primarily in the midbrain, pons and right temporal lobe.

Conclusion:
Elevated GM volume in CFS is seen in areas related to processing of interoceptive signals and stress. Reduced WM volume in the patient group partially supports earlier findings of WM abnormalities in regions of the midbrain and brainstem.

ME Association comment: MEA Review: Grey and white matter differences in chronic fatigue syndrome

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Sleep quality in adolescents with CFS/ME

Research abstract:

Sleep quality in adolescents with Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME), by EK Josev, ML Jackson, B Bei, J Trinder, A Harvey, C Clarke, K Snodgrass, A Scheinberg, SJ Knight in J Clin Sleep Med. 2017 Sep 15; 13(9):1057-1066

 

Study objectives:

Little is known about the type and severity of sleep disturbances in the pediatric chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) population, compared with healthy adolescents. Using a range of objective and subjective measures, the aim of this study was to investigate sleep quality, the relationship between objective and subjective measures of sleep quality, and their associations with anxiety in adolescents with CFS/ME compared with healthy controls.

Methods:

Twenty-one adolescents with CFS/ME aged 13 to 18 years (mean age 15.57 ± 1.40), and 145 healthy adolescents aged 13 to 18 years (mean age 16.2 ± 1.00) wore actigraphy watches continuously for 2 weeks to collect a number of objective sleep variables. The Pittsburgh Sleep Quality Index was used to obtain a subjective measure of sleep quality. Anxiety was measured by the Spence Children’s Anxiety scale.

Results:

On average over the 2-week period, adolescents with CFS/ME were found to have (1) significantly longer objective sleep onset latency, time in bed, total sleep time, and a later rise time (all P < .005), and (2) significantly poorer subjective sleep quality (P < .001), compared with healthy adolescents. The CFS/ME patient group displayed higher levels of anxiety (P < .05), and in both groups, higher levels of anxiety were significantly related to poorer subjective sleep quality (P < .001).

Conclusions:

This study provides objective and subjective evidence of sleep disturbance in adolescents with CFS/ME compared with healthy adolescent controls.

 

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