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The association of psychological factors and healthcare use with the discrepancy between subjective and objective respiratory-health complaints in the general population

Published online by Cambridge University Press:  20 March 2018

Sanna Selinheimo ,
Tuula Vasankari ,
Markus Jokela ,
Merja Kanervisto ,
Sami Pirkola ,
Jaana Suvisaari  and
Tiina Paunio
Sanna Selinheimo*
Affiliation:
Finnish Institute of Occupational Health, Helsinki, Finland Department of Health, National Institute for Health and Welfare, Helsinki, Finland Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
Tuula Vasankari
Affiliation:
Finnish Lung Health Association, Helsinki, Finland Department of Pulmonary Diseases and Clinical Allergology, University of Turku, Turku, Finland
Markus Jokela
Affiliation:
Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
Merja Kanervisto
Affiliation:
Independent Science Researcher Ylöjärvi, Finland
Sami Pirkola
Affiliation:
Health Sciences, and University Hospital Psychiatric Department, University of Tampere, Tampere, Finland
Jaana Suvisaari
Affiliation:
Department of Health, National Institute for Health and Welfare, Helsinki, Finland
Tiina Paunio
Affiliation:
Finnish Institute of Occupational Health, Helsinki, Finland Department of Health, National Institute for Health and Welfare, Helsinki, Finland Department of Psychiatry, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
*
Author for correspondence: Sanna Selinheimo, E-mail: [email protected] or Tiina Paunio, E-mail: [email protected]
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Abstract

Background

We examined the prevalence of self-perceived respiratory symptoms (SRS) in the absence of any objective findings of respiratory pathology, and the association of such prevalence with psychological factors and healthcare use in the general population.

Methods

The study was conducted among a nationally representative sample of Finnish adults (BRIF8901). Respiratory functioning was measured by a spirometry test. Structured questionnaires were used to measure SRS, physician visits and psychological factors of alexithymia, sense of coherence, illness worry and common mental disorders. Individuals with a diagnosed respiratory disease or a severe psychiatric disorder, determined in a diagnostic interview, were excluded, giving a sample comprising 4544 participants.

Results

Twenty-six per cent of the general population and 36% of those with no diagnosed severe psychiatric disorder or respiratory disease experienced SRS despite a normal spirometry result. Psychological factors were associated with SRS (0.0001 < p < 0.032), and on the number of physician visit explaining 42.7% of the difference in visits between individuals with and without SRS, respectively. Illness worry was associated most strongly with SRS [odds ratio (OR) 1.29, 95% confidence interval (CI) 1.19–1.41, p < 0.0001] and higher numbers of physician visits (OR 1.35, CI 1.32–1.38, p < 0.00001), even after several adjustments.

Conclusions

Respiratory symptoms without objective findings are common in the general population. The study results underline the role of psychological factors in the reporting of respiratory symptoms and the associated medical burden, thereby indicating the functional nature of the symptomatology.

Keywords

Alexithymiahealth anxietyhealthcare useillness perceptionpopulation-based studyrespiratory symptomssense of coherencesubjective health complaints
Type
Original Articles
Information
Psychological Medicine , Volume 49 , Issue 1 , January 2019 , pp. 121 - 131
Copyright
Copyright © Cambridge University Press 2018 

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References

Agardh, EE, Ahlbom, A, Andersson, T, Efendic, S, Grill, V, Hallqvist, J, Norman, A and Östenson, C-G (2003) Work stress and low sense of coherence is associated with type 2 diabetes in middle-aged Swedish women. Diabetes Care 26, 719–724.Google Scholar
Antonovsky, A (1987) Unraveling the Mystery of Health: How People Manage Stress and Stay Well. San Francisco: Jossey-Bass.Google Scholar
Aromaa, A and Koskinen, S (eds.) (2004). Health and Functional Capacity in Finland. Baseline Results of the Health 2000 Health Examination Survey. Helsinki: Publications of the National Public Health Institute = Kansanterveyslaitos.Google Scholar
Bagby, RM, Parker, JD and Taylor, GJ (1994 a) The twenty-item Toronto Alexithymia Scale-I. Item selection and cross-validation of the factor structure. Journal of Psychosomatic Research 38, 23–32.Google Scholar
Bagby, RM, Taylor, GJ and Parker, JD (1994 b) The twenty-item Toronto Alexithymia Scale-II. Convergent, discriminant, and concurrent validity. Journal of Psychosomatic Research 38, 33–40.Google Scholar
Baiardini, I, Braido, F, Ferraioli, G, Menoni, S, Bruzzone, M, Conte, ME, Gani, F, Ridolo, E, Scordamaglia, A and Canonica, GW (2011) Pitfalls in respiratory allergy management: alexithymia and its impact on patient-reported outcomes. Journal of Asthma 48, 25–32.Google Scholar
Bailey, PE and Henry, JD (2007) Alexithymia, somatization and negative affect in a community sample. Psychiatry Research 150, 13–20.Google Scholar
Barsky, AJ and Borus, JF (1999) Functional somatic syndromes. Annals of Internal Medicine 130, 910–921.Google Scholar
Barsky, AJ, Ettner, SL, Horsky, J and Bates, DW (2001 a) Resource utilization of patients with hypochondriacal health anxiety and somatization. Medical Care 39, 705–715.Google Scholar
Barsky, AJ, Orav, EJ and Bates, DW (2005) Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity. Archives General Psychiatry 62, 903–910.Google Scholar
Barsky, AJ, Peekna, HM and Borus, JF (2001 b) Somatic symptom reporting in women and men. Journal of General Internal Medicine 16, 266–275.Google Scholar
Bernabe, E, Tsakos, G, Watt, RG, Suominen-Taipale, AL, Uutela, A, Vahtera, J and Kivimaki, M (2009) Structure of the sense of coherence scale in a nationally representative sample: the Finnish Health 2000 survey. Quality of Life Research 18, 629–636.Google Scholar
Bhandari, A and Wagner, T (2006) Self-reported utilization of health care services: improving measurement and accuracy. Medical Care Research and Review 63, 217–235.Google Scholar
Bleichhardt, G and Hiller, W (2007) Hypochondriasis and health anxiety in the German population. British Journal of Health Psychology 12, 511–523.Google Scholar
Bogaerts, K, Notebaert, K, Van Diest, I, Devriese, S, De Peuter, S and Van den Bergh, O (2005) Accuracy of respiratory symptom perception in different affective contexts. Journal of Psychosomatic Research 58, 537–543.Google Scholar
Bogaerts, K, Van Eylen, L, Li, W, Bresseleers, J, Van Diest, I, De Peuter, S, Stans, L, Decramer, M and Van den Bergh, O (2010) Distorted symptom perception in patients with medically unexplained symptoms. Journal of Abnormal Psychology 119, 226.Google Scholar
Brunner, WM, Schreiner, PJ, Sood, A and Jacobs, DR Jr. (2014) Depression and risk of incident asthma in adults. The CARDIA study. American Journal of Respiratory and Critical Care Medicine 189, 1044–1051.Google Scholar
Burton, C (2003) Beyond somatisation: a review of the understanding and treatment of medically unexplained physical symptoms (MUPS). The British Journal of General Practice 53, 231–239.Google Scholar
Clarke, DM, Piterman, L, Byrne, CJ and Austin, DW (2008) Somatic symptoms, hypochondriasis and psychological distress: a study of somatisation in Australian general practice. Medical Journal of Australia 189, 560.Google Scholar
Cohen, S, Doyle, WJ, Turner, RB, Alper, CM and Skoner, DP (2003) Emotional style and susceptibility to the common cold. Psychosomatic Medicine 65, 652–657.Google Scholar
Creed, F and Barsky, A (2004) A systematic review of the epidemiology of somatisation disorder and hypochondriasis. Journal of Psychosomatic Research 56, 391–408.Google Scholar
Deary, IJ, Scott, S and Wilson, JA (1997) Neuroticism, alexithymia and medically unexplained symptoms. Personality and Individual Differences 22, 551–564.Google Scholar
De Gucht, V and Heiser, W (2003) Alexithymia and somatisation: a quantitative review of the literature. Journal of Psychosomatic Research 54, 425–434.Google Scholar
Disler, R, Gallagher, R and Davidson, P (2012) Factors influencing self-management in chronic obstructive pulmonary disease: an integrative review. International Journal of Nursing Studies 49, 230–242.Google Scholar
Eisner, MD, Katz, PP, Lactao, G and Iribarren, C (2005) Impact of depressive symptoms on adult asthma outcomes. Annals of Allergy, Asthma & Immunology 94, 566–574.Google Scholar
Eliasen, M, Kreiner, S, Ebstrup, JF, Poulsen, CH, Lau, CJ, Skovbjerg, S, Fink, PK and Jørgensen, T (2016) Somatic symptoms: prevalence, co-occurrence and associations with self-perceived health and limitations due to physical health – a Danish population-based study. PLoS ONE 11, e0150664.Google Scholar
Eriksson, M and Lindström, B (2005) Validity of Antonovsky's sense of coherence scale: a systematic review. Journal of Epidemiology and Community Health 59, 460–466.Google Scholar
Eriksson, M and Lindström, B (2006) Antonovsky's sense of coherence scale and the relation with health: a systematic review. Journal of Epidemiology and Community Health 60, 376–381.Google Scholar
Feldman, JM, Lehrer, PM and Hochron, SM (2002) The predictive value of the Toronto Alexithymia Scale among patients with asthma. Journal of Psychosomatic Research 53, 1049–1052.Google Scholar
Fink, P, Ewald, H, Jensen, J, Sørensen, L, Engberg, M, Holm, M and Munk-Jørgensen, P (1999) Screening for somatization and hypochondriasis in primary care and neurological in-patients: a seven-item scale for hypochondriasis and somatization. Journal of Psychosomatic Research 46, 261–273.Google Scholar
Fletcher, CM, Elmes, PC, Fairbairn, AS and Wood, CH (1959) The significance of respiratory symptoms and the diagnosis of chronic bronchitis in a working population. British Medical Journal 2, 257–266.Google Scholar
Frostholm, L, Fink, P, Christensen, KS, Toft, T, Oernboel, E, Olesen, F and Weinman, J (2005) The patients’ illness perceptions and the use of primary health care. Psychosomatic Medicine 67, 997–1005.Google Scholar
Frostholm, L, Oernboel, E, Christensen, KS, Toft, T, Olesen, F, Weinman, J and Fink, P (2007). Do illness perceptions predict health outcomes in primary care patients? A 2-year follow-up study. Journal of Psychosomatic Research 62, 129–138.Google Scholar
Gallagher, R, Donoghue, J, Chenoweth, L and Stein-Parbury, J (2008) Self-management in older patients with chronic illness. International Journal of Nursing Practice 14, 373–382.Google Scholar
Goodwin, R and Engstrom, G (2002) Personality and the perception of health in the general population. Psychological Medicine 32, 325–332.Google Scholar
Haug, TT, Mykletun, A and Dahl, AA (2004) The association between anxiety, depression, and somatic symptoms in a large population: the HUNT-II study. Psychosomatic Medicine 66, 845–851.Google Scholar
Henningsen, P, Zimmermann, T and Sattel, H (2003) Medically unexplained physical symptoms, anxiety, and depression: a meta-analytic review. Psychosomatic Medicine 65, 528–533.Google Scholar
Henningsen, P, Zipfel, S and Herzog, W (2007) Management of functional somatic syndromes. The Lancet 369, 946–955.Google Scholar
Hiirola, A, Pirkola, S, Karukivi, M, Markkula, N, Bagby, R, Joukamaa, M, Jula, A, Kronholm, E, Saarijärvi, S and Salminen, J (2017) An evaluation of the absolute and relative stability of alexithymia over 11years in a Finnish general population. Journal of Psychosomatic Research 95, 81–87.Google Scholar
Hynninen, KMJ, Breitve, MH, Wiborg, AB, Pallesen, S and Nordhus, IH (2005) Psychological characteristics of patients with chronic obstructive pulmonary disease: a review. Journal of Psychosomatic Research 59, 429–443.Google Scholar
Janssens, T, Verleden, G, De Peuter, S, Petersen, S and Van den Bergh, O (2011) The influence of fear of symptoms and perceived control on asthma symptom perception. Journal of Psychosomatic Research 71, 154–159.Google Scholar
Joukamaa, M, Miettunen, J, Kokkonen, P, Koskinen, M, Julkunen, J, Kauhanen, J, Jokelainen, J, Veijola, J, Laksy, K and Jarvelin, MR (2001) Psychometric properties of the Finnish 20-item Toronto Alexithymia Scale. Nordic Journal of Psychiatry 55, 123–127.Google Scholar
Jyväsjärvi, S, Joukamaa, M, Väisänen, E, Larivaara, P, Kivelä, S-L and Keinänen-Kiukaanniemi, S (2001) Somatizing frequent attenders in primary health care. Journal of Psychosomatic Research 50, 185–192.Google Scholar
Katon, W, Lin, EH and Kroenke, K (2007) The association of depression and anxiety with medical symptom burden in patients with chronic medical illness. General Hospital Psychiatry 29, 147–155.Google Scholar
Katon, WJ and Walker, EA (1998) Medically unexplained symptoms in primary care. The Journal of Clinical Psychiatry 59(Suppl 20), 15–21.Google Scholar
Kirmayer, LJ, Groleau, D, Looper, KJ and Dao, MD (2004) Explaining medically unexplained symptoms. The Canadian Journal of Psychiatry 49, 663–672.Google Scholar
Kivimäki, M, Feldt, T, Vahtera, J and Nurmi, J-E (2000) Sense of coherence and health: evidence from two cross-lagged longitudinal samples. Social Science & Medicine 50, 583–597.Google Scholar
Kolk, A, Hanewald, G, Schagen, S and van Wijk, CG (2002) Predicting medically unexplained physical symptoms and health care utilization: a symptom-perception approach. Journal of Psychosomatic Research 52, 35–44.Google Scholar
Kooiman, CG, Bolk, JH, Rooijmans, HG and Trijsburg, RW (2004) Alexithymia does not predict the persistence of medically unexplained physical symptoms. Psychosomatic Medicine 66, 224–232.Google Scholar
Kroenke, K and Spitzer, RL (1998) Gender differences in the reporting of physical and somatoform symptoms. Psychosomatic Medicine 60, 150–155.Google Scholar
Kroenke, K, Spitzer, RL and Williams, JB (2002) The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosomatic Medicine 64, 258–266.Google Scholar
Lehrer, P, Feldman, J, Giardino, N, Song, H-S and Schmaling, K (2002) Psychological aspects of asthma. Journal of Consulting and Clinical Psychology 70, 691.Google Scholar
Loengaard, K, Bjorner, JB, Fink, PK, Burr, H and Rugulies, R (2015) Medically unexplained symptoms and the risk of loss of labor market participation – a prospective study in the Danish population. BioMedCentral Public Health 15, 844.Google Scholar
Löwe, B, Spitzer, RL, Williams, JB, Mussell, M, Schellberg, D and Kroenke, K (2008) Depression, anxiety and somatization in primary care: syndrome overlap and functional impairment. General Hospital Psychiatry 30, 191–199.Google Scholar
Lundh, LG and Simonsson-Sarnecki, M (2001) Alexithymia, emotion, and somatic complaints. Journal of Personality 69, 483–510.Google Scholar
Mattila, AK, Kronholm, E, Jula, A, Salminen, JK, Koivisto, A-M, Mielonen, R-L and Joukamaa, M (2008) Alexithymia and somatization in general population. Psychosomatic Medicine 70, 716–722.Google Scholar
Michael, CS, Callahan, CM, Counsell, SR, Westmoreland, GR, Stump, TE and Kroenke, K (2005) Physical symptoms as a predictor of health care use and mortality among older adults. The American Journal of Medicine 118, 301–306.Google Scholar
Nici, L, Donner, C, Wouters, E, Zuwallack, R, Ambrosino, N, Bourbeau, J, Carone, M, Celli, B, Engelen, M and Fahy, B (2006) American thoracic society/European respiratory society statement on pulmonary rehabilitation. American Journal of Respiratory and Critical Care Medicine 173, 1390–1413.Google Scholar
Nimnuan, C, Hotopf, M and Wessely, S (2001) Medically unexplained symptoms: an epidemiological study in seven specialities. Journal of Psychosomatic Research 51, 361–367.Google Scholar
olde Hartman, TC, Borghuis, MS, Lucassen, PL, van de Laar, FA, Speckens, AE and van Weel, C (2009) Medically unexplained symptoms, somatisation disorder and hypochondriasis: course and prognosis. A systematic review. Journal of Psychosomatic Research 66, 363–377.Google Scholar
Owens, KM, Asmundson, GJ, Hadjistavropoulos, T and Owens, TJ (2004) Attentional bias toward illness threat in individuals with elevated health anxiety. Cognitive Therapy and Research 28, 57–66.Google Scholar
Pallant, JF and Lae, L (2002) Sense of coherence, well-being, coping and personality factors: further evaluation of the sense of coherence scale. Personality and Individual Differences 33, 39–48.Google Scholar
Perala, J, Suvisaari, J, Saarni, SI, Kuoppasalmi, K, Isometsa, E, Pirkola, S and Partonen, T, Tuulio-Henriksson, A, Hintikka, J, Kieseppa, T, Harkanen, T, Koskinen, S and Lonnqvist, J (2007) Lifetime prevalence of psychotic and bipolar I disorders in a general population. Archives of General Psychiatry 64, 19–28.Google Scholar
Petrie, KJ, Faasse, K, Crichton, F and Grey, A (2014) How common are symptoms? Evidence from a New Zealand national telephone survey. British Medical Journal Open 4, e005374.Google Scholar
Petrie, KJ and Weinman, J (2012) Patients’ perceptions of their illness: the dynamo of volition in health care. Current Directions in Psychological Science 21, 60–65.Google Scholar
Pilowsky, I (1967) Dimensions of hypochondriasis. The British Journal of Psychiatry 113, 89–93.Google Scholar
Pirkola, SP, Isometsä, E, Suvisaari, J, Aro, H, Joukamaa, M, Poikolainen, K, Koskinen, S, Aromaa, A and Lönnqvist, JK (2005) DSM-IV mood-, anxiety- and alcohol use disorders and their comorbidity in the Finnish general population. Social Psychiatry and Psychiatric Epidemiology 40, 1–10.Google Scholar
Poppius, E, Tenkanen, L, Kalimo, R and Heinsalmi, P (1999) The sense of coherence, occupation and the risk of coronary heart disease in the Helsinki Heart Study. Social Science & Medicine 49, 109–120.Google Scholar
Quanjer, PH, Stanojevic, S, Cole, TJ, Baur, X, Hall, GL, Culver, BH, Enright, PL, Hankinson, JL, Ip, MS and Zheng, J (2012) Multi-ethnic reference values for spirometry for the 3–95-yr age range: the global lung function 2012 equations. European Respiratory Journal 40, 1324–1343.Google Scholar
Reid, S, Wessely, S, Crayford, T and Hotopf, M (2001) Medically unexplained symptoms in frequent attenders of secondary health care: retrospective cohort study. British Medical Journal 322, 767.Google Scholar
Rhee, H, Belyea, MJ and Halterman, JS (2011) Adolescents’ perception of asthma symptoms and health care utilization. Journal of Pediatric Health Care 25, 105–113.Google Scholar
Rief, W, Hessel, A and Braehler, E (2001) Somatization symptoms and hypochondriacal features in the general population. Psychosomatic Medicine 63, 595–602.Google Scholar
Robbins, JM and Kirmayer, LJ (1991) Attributions of common somatic symptoms. Psychological Medicine 21, 1029–1045.Google Scholar
Robbins, JM and Kirmayer, LJ (1996) Transient and persistent hypochondriacal worry in primary care. Psychological Medicine 26, 575–589.Google Scholar
Rose, GA and Blackburn, H (1968) Cardiovascular Survey Methods. Geneva: World Health Organization.Google Scholar
Serrano, J, Plaza, V, Sureda, B, De Pablo, J, Picado, C, Bardagi, S, Lamela, J, Sanchis, J and Group SHRAR (2006) Alexithymia: a relevant psychological variable in near-fatal asthma. European Respiratory Journal 28, 296–302.Google Scholar
Short, ME, Goetzel, RZ, Pei, X, Tabrizi, MJ, Ozminkowski, RJ, Gibson, TB, DeJoy, DM and Wilson, MG (2009) How accurate are self-reports? An analysis of self-reported healthcare utilization and absence when compared to administrative data. Journal of Occupational and Environmental Medicine/American College of Occupational and Environmental Medicine 51, 786.Google Scholar
Simon, G, Gater, R, Kisely, S and Piccinelli, M (1996) Somatic symptoms of distress: an international primary care study. Psychosomatic Medicine 58, 481–488.Google Scholar
Simonsson, B, Nilsson, KW, Leppert, J and Diwan, VK (2008) Psychosomatic complaints and sense of coherence among adolescents in a county in Sweden: a cross-sectional school survey. BioPsychoSocial Medicine 2, 1.Google Scholar
Speckens, AE, Spinhoven, P, Sloekers, PP, Bolk, JH and van Hemert, AM (1996) A validation study of the Whitely Index, the Illness Attitude Scales, and the Somatosensory Amplification Scale in general medical and general practice patients. Journal of Psychosomatic Research 40, 95–104.Google Scholar
Steinbrecher, N, Koerber, S, Frieser, D and Hiller, W (2011) The prevalence of medically unexplained symptoms in primary care. Psychosomatics 52, 263–271.Google Scholar
Stewart, DE and Yuen, T (2011) A systematic review of resilience in the physically ill. Psychosomatics 52, 199–209.Google Scholar
Sunderland, M, Newby, JM and Andrews, G (2013) Health anxiety in Australia: prevalence, comorbidity, disability and service use. The British Journal of Psychiatry 202, 56–61.Google Scholar
Suominen, S, Helenius, H, Blomberg, H, Uutela, A and Koskenvuo, M (2001) Sense of coherence as a predictor of subjective state of health: results of 4 years of follow-up of adults. Journal of Psychosomatic Research 50, 77–86.Google Scholar
Taylor, GJ, Bagby, RM and Parker, JD (1999) Disorders of Affect Regulation: Alexithymia in Medical and Psychiatric Illness. Cambridge: Cambridge University Press.Google Scholar
Tomenson, B, Essau, C, Jacobi, F, Ladwig, KH, Leiknes, KA, Lieb, R, Meinlschmidt, G, McBeth, J, Rosmalen, J and Rief, W (2013) Total somatic symptom score as a predictor of health outcome in somatic symptom disorders. The British Journal of Psychiatry 203, 373–380.Google Scholar
Tyrer, P, Cooper, S, Crawford, M, Dupont, S, Green, J, Murphy, D, Salkovskis, P, Smith, G, Wang, D and Bhogal, S (2011) Prevalence of health anxiety problems in medical clinics. Journal of Psychosomatic Research 71, 392–394.Google Scholar
van der Sluijs, J, Ten Have, M, Rijnders, C, van Marwijk, H, de Graaf, R and van der Feltz-Cornelis, C (2015) Medically unexplained and explained physical symptoms in the general population: association with prevalent and incident mental disorders. PLoS ONE 10, e0123274.Google Scholar
Vazquez, I, Sández, E, González-Freire, B, Romero-Frais, E, Blanco-Aparicio, M and Verea-Hernando, H (2010) The role of alexithymia in quality of life and health care use in asthma. Journal of Asthma 47, 797–804.Google Scholar
Waller, E and Scheidt, CE (2006) Somatoform disorders as disorders of affect regulation: a development perspective. International Review of Psychiatry 18, 13–24.Google Scholar
Watson, D and Pennebaker, JW (1989) Health complaints, stress, and distress: exploring the central role of negative affectivity. Psychological Review 96, 234.Google Scholar
World Health Organization (1993) Composite International Diagnostic Interview (CIDI), Version 1.1. Geneva: World Health Organization.Google Scholar
World Health Organization (1997) Composite International Diagnostic Interview (CIDI), Version 2.1. Geneva: World Health Organization.Google Scholar
Yorke, J, Fleming, SL and Shuldham, C (2007) Psychological interventions for adults with asthma: a systematic review. Respiratory Medicine 101, 1–14.Google Scholar
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