Presentation on theme: "Management of Depression in the Primary Care Setting"— Presentation transcript:
1 Management of Depression in the Primary Care Setting Alan L. Podawiltz, D.O., M.S.Chair, Psychiatry and Behavioral Health
2 Learning ObjectivesAfter your participation in this session you should be able to:DESCRIBE the epidemiology of depressive disorders.DESCRIBE symptoms of depressive disorders.DIFFERENTIATE/DIAGNOSE the characteristics of depressive disordersDESCRIBE drugs and medical illnesses that may induce depressionDESCRIBE physiologic abnormalities caused by psychotropic medications:DESCRIBE common adverse effects of psychotropic agentsDESCRIBE strategies to assist the compliance of patients with recommended treatment.Impact of illness on activities of daily living,Early developmentAccess to diagnosis and treatmentCultural influence on illness
5 Major Depressive Disorder Lifetime prevalence in women: 21.3%1Lifetime prevalence in men: 12.7%1Most prevalent in women between onset of menstruation and menopause2Kessler RC et al. Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Arch Gen Psychiatry. 1999;56(7):Cohen LS et al. H. Diagnosis and management of mood disorders during the menopausal transition. Am J Med. 2005;118 Suppl 12B:93-97.
6 Risk of Depression by Age & Sex Kessler R, et al. J Affect Disord. 1993; 29:85-96.
7 Comorbidity and Depression 72.1% of those with lifetime MDD and 64% of those with 12-month MDD have at least one additional mood disorderPrimarily anxiety disorder, substance abuse disorder, or impulse control disorderKessler RC et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003;289(23):
8 Major Depressive Disorder (MDD) One or more major depressive episodesAbsence of any history of manic, mixed, or hypomanic episodesRelapsing and remittingEpisodes may last months or, more rarely, yearsHalf of all episodes fully remit within 6 to 12 months with or without treatmentUp to 20% of those who experience an initial episode may develop chronic depressionAfter an initial episode, the patient is predisposed to additional episodes which become more severe and last longerMoore DP, Jefferson JW. Mood Disorders. In: Moore & Jefferson: Handbook of Medical Psychiatry, 2nd ed. Philadelphia: Mosby; 2004
9 Depression Very common Associated with significant dysfunction Under diagnosedOften chronic or recurrentCommonly present with other GMCHighly treatableMultiple safe and effective treatments are available
10 Major Depressive Disorder Relapsing and remitting courseMay eventually become chronicMinimum duration ≥ two weeksClear distinction between episodes and inter- episodic functionOften well or at least much better between episodes
11 Over the last two weeks: Two QuestionsOver the last two weeks:Have you felt down, depressed, or hopeless? (Mood)Have you felt little interest or pleasure in doing things? (Interest)
12 Two-Steps for Depression Screening Step One: Two-Question Depression ScreenStep Two: If Screen is Positive…Over the past 2 weeks have you felt down, depressed, or hopeless?Over the past 2 weeks have you felt little interest or pleasure in doing things?Probe deeper, be proactive, engage in conversation about mood and changes in behavior24% - 40% of patients with positive screen receive MDD diagnosisOthers may have dysthmia, subsyndromal depressive disorders, anxiety, PTSD, substance abuse, panic disorder, or grief disorderA “yes” to either question is a positive initial screen for depression…US Preventive Services Task Force. Screening for depression: recommendations and rationale. Ann Intern Med. 2002;136(10):
13 Visual Screening ToolAsk the patient to point to the face that best represents how she/he has felt in the past 2 weeks.Depression in Women Series, PACE, 2007
14 Recommended Instruments QIDS: Quick Inventory of Depressive Symptomatology (http://www.ids-qids.org)PHQ-9: Patient Health Questionnaire-9 (www.phqscreeners.com)Both instruments are…ValidatedQuickly and easily administered and scoredAvailable to downloadAvailable in English and SpanishHelpful for initial screening AND evaluation of treatment response
15 SIGECAPSSIGECAP- Changes in sleep pattern - Changes in interests or activity - Feelings of guilt or increased worry - Changes in energy - Changes in concentration - Changes in appetite - Psychomotor disturbances - Suicidal ideation
16 Major Depressive Disorder Core symptoms: SIGECAPSDepressed mood (sad, down, blue) AND/ORReduced interest or pleasure (I)Somatic symptoms:Change in appetite (A)Change in sleep pattern (S)Reduced energy level (E)Psychomotor agitation/retardation (P)Cognitive symptoms:Poor concentration/easy distraction (C)Inappropriate guilt/self reproach (G)Thoughts of death, dying, suicide (S)5 out of 9 for at least two weeks
17 The Suicide QuestionIf an adult, child, or adolescent says, “I want to kill myself, or I'm going to commit suicide” Always take this statement seriously and immediately seek assistance from a qualified mental health professional People often feel uncomfortable talking about death. However, asking the adult, child, or adolescent whether he or she is depressed or thinking about suicide can be helpful. Rather than putting thoughts in the person's head, such a question will provide assurance that somebody cares and will give the person the chance to talk about problems
18 U.S. Suicides 11th leading cause of death 8th leading cause of death for males19th leading cause of death for females1.3% deaths suicide29% heart diseases23% malignant neoplasms6.8% cerebrovascular disease
19 Suicide Risk Screening MeasureSuicide Risk Screening QuestionsScoreIdeationHave you had thoughts of taking your own life1PlansHave made any plans to take your life?MeansDo you have access to the tools or situation to take your life according to your plan?IntentDo you intend to commit suicide? When?HistoryHave you ever tried to take your own life?TotalDepression in Women Series, PACE, 2007
20 Suicide Risk Assessment ScoreSuicide RiskTreatment RecommendationLow RiskFollow Up as needed1-2Moderate RiskAssess suicide risk at each visit.Refer as needed3-5High RiskImplement protective measuresand emergent managementDepression in Women Series, PACE, 2007
21 Explore the Differentials Depressive DisordersPsychiatricMajor PsychosesAdjustment D/O w/ depressionBereavement (up to 2 months)General MedicalHypothyroidism = classic rule-outPost-CVA, Post-MICa of head of pancreasSubstance-RelatedAlcohol abuse, cocaine/amphetamine withdrawalRx meds: steroids, b-blockers, a-methyldopa
22 Comorbid Medical Conditions Asthma1 Pain2 Arthritis1 Cardiovascular disease1 Stroke3 Diabetes1 Obesity1Chapman DP et al. The vital link between chronic disease and depressive disorders. Prev Chronic Dis. 2005;2(1):A14.Gureje O et al. A cross-national study of the course of persistent pain in primary care. Pain. 2001;92(1-2):Gillen R et al. Depressive symptoms and history of depression predict rehabilitation efficiency in stroke patients. Arch Phys Med Rehabil. 2001;82(12):
23 Substances Related to Sexual Dysfunction AntidepressantsLithiumSympathomimetics and - adrenergic antagonistsAnticholinergicsAntihistaminesAnti-anxiety agentsAlcoholOpioidsHallucinogensCannabisBarbituratesSedative hypnotics
24 Sexual Dysfunction and Antidepressants Selective Serotonin Reuptake Inhibitors (SSRIs)Increases serotonin levels in both sexesDecreases sex driveImpairs orgasm5HT2A AgonistTricyclic Antidepressants (TCAs)Drying of mucosal membranesReduction of lubricationStimulation of 5HT2A receptorsInhibits erection and ejaculation
25 CVD and DepressionPatients with cardiovascular disease (CVD) more likely to experience depression1Patients with depression 1.6 times more likely to develop coronary artery disease (CAD); even more likely with MDD1Also 4 times more likely to experience a myocardial infarction (MI)1Post-MI patients with depression less likely to follow lifestyle changes2Pratt LA et al. Depression, psychotropic medication, and risk of myocardial infarction. Prospective data from the Baltimore ECA follow-up. Circulation. 1996;94(12):Ziegelstein RC et al. Patients with depression are less likely to follow recommendations to reduce cardiac risk during recovery from a myocardial infarction. Arch Intern Med. 2000;160(12):
26 Depression and Diabetes Depression twice as prevalent in those with diabetesMore prevalent in women with diabetes than in men with diabetesAnderson RJ et al. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care. 2001;24(6):
27 Depression and Obesity 65% of the US population is overweight or obeseMore obese women than men (54% vs. 46%)1BMI ≥30 in women associated with nearly 50% increase in lifetime prevalence of depressive disorders2Ogden CL et al. Prevalence of overweight and obesity in the United States, JAMA. 2006;295(13):Chapman DP et al. The vital link between chronic disease and depressive disorders. Prev Chronic Dis. 2005;2(1):A14.
28 Practice Recommendation Screen patients with any chronic health condition for depression, especially patients with diabetes, cardiovascular disease, or chronic pain.So here is your first practice recommendation. Quite simply: Screen any patients with chronic health conditions for depression, especially those with diabetes, cardiovascular disease, or chronic pain.Source: US Preventive Services Task Force. Screening for depression: recommendations and rationale. Ann Intern Med. 2002;136(10):US Preventive Services Task Force. Screening for depression: recommendations and rationale. Ann Intern Med. 2002;136(10):AAFP Approved source: Institute for Clinical Systems ImprovementWebsite:Strength of Evidence: Grade A (randomized, controlled trials)
29 Study of Women’s Health Across the Nation (SWAN) Depression risk highest in:Early or late perimenopauseUsing hormone therapy (OR=1.30 – 1.71)Late vs. early perimenopauseBromberger JT et al. Depressive symptoms during the menopausal transition: The Study of Women's Health Across the Nation (SWAN). J Affect Disord. 2007
30 Harvard Study of Moods and Cycles Nearly twofold increased risk of depression in women entering perimenopause (OR=1.8)Hot flushes associated with greater risk of MDD (OR=2.2)Cohen LS et al. Diagnosis and management of mood disorders during the menopausal transition. Am J Med. 2005;118 Suppl 12B:93-97.
31 Major Neurotransmitters SerotoninNorepinephrineAnxietyIrritabilityEnergyInterestImpulsivityMood, Emotion, Cognitive functionSexAppetiteAggressionMotivationDriveDopamine
32 Role of Serotonin in the CNS Serotonin influences a wide variety of brain functionsMoodSleepCognitionSensory perceptionTemperature regulationNociception (e.g., migraine headache)AppetiteSexual behaviorKaplan HI, Sadock BJ. In: Synopsis of Psychiatry: Behavioral Sciences,Clinical Psychiatry, 8th edHardman JG, et al. In: Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 9th edNemeroff C. Scientific American. June 1998;42-49.
33 Role of Dopamine in the CNS Dopamine modulates various brain functionsMoodCognitionMotor functionDriveAggressionMotivationKaplan HI, Sadock BJ. In: Synopsis of Psychiatry: Behavioral Sciences,Clinical Psychiatry, 8th edHardman JG, et al. In: Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 9th ed
34 Role of Norepinephrine in the CNS Norepinephrine plays an important role in the brain affectingMoodLearning and memoryRegulation of sleep-wake cycleRegulation of hypothalamic-pituitary axisRegulation of sympathetic nervous systemSlide 9Kaplan HI, Sadock BJ. In: Synopsis of Psychiatry: Behavioral Sciences,Clinical Psychiatry, 8th edNemeroff C. Scientific American. June 1998;42-49.Frazer A. J Clin Psychiatry. 2000;61(suppl 10)25-30.
35 Undertreatment Evidence Lewis, et al.1/3 discontinued medicationLin, et al.50% received no follow-up visitMore than 1/3 had not refilled antidepressantSimon, et al.Fewer than half had adequate treatment for their depressionIn Lewis et al., 37.1% of 26,888 adults who filled a prescription for any SSRI and who were eligible for prescription benefits for at least 180 days discontinued their medication.1 Current guidelines recommend continuing antidepressants in patients who achieve symptom remission for at least an additional 6-12 months.2In another study, Lin et al assessed 1671 patients diagnosed with depression 6 to 8 weeks after they started pharmacotherapy under the direction of one of four primary care clinics. The researchers found 42.3% of patients were at high risk of relapse; 24.5% were persistently depressed with 4 or more depressive symptoms. Half the patients received no follow-up visit for their depression, and between 32%-42% had not refilled their antidepressant.Finally, in another study of 1550 patients, 67% of whom were women, less than half had adequate treatment for their depression.Lewis E, et al. Patients' early discontinuation of antidepressant prescriptions. Psychiatr Serv. 2004;55(5):494.Kaiser Permanente Care Management Institute. Depression clinical practice guidelines. Accessed May 2, 2007.Lin EH et al. Low-intensity treatment of depression in primary care: is it problematic? Gen Hosp Psychiatry. 2000;22(2):78-83.Simon GE et al. Treatment process and outcomes for managed care patients receiving new antidepressant prescriptions from psychiatrists and primary care physicians. Arch Gen Psychiatry. 2001;58(4):Lewis E, et al. Patients' early discontinuation of antidepressant prescriptions. Psychiatr Serv. 2004;55(5):494.Lin EH et al. Low-intensity treatment of depression in primary care: is it problematic? Gen Hosp Psychiatry. 2000;22(2):78-83.Simon GE et al. Treatment process and outcomes for managed care patients receiving new antidepressant prescriptions from psychiatrists and primary care physicians. Arch Gen Psychiatry. 2001;58(4):
36 Patient AdherencePatients are often reluctant to engage in therapy.1More than half of patients treated for depression in primary care practices stopped drug treatment within 3 weeks. 2Why??Weren’t told how long it would take to feel betterWeren’t warned about side effectsWeren’t told I needed to continue once I felt better2Once diagnosed, patients themselves contribute to the undertreatment of MDD. One review found that more than half of patients treated for depression in primary care practices stopped drug treatment within 3 weeks. Such noncompliance may be due to the length of time necessary for clinical improvement, and lack of information about the medication’s adverse effects and the need to continue treatment beyond the initial clinical response.1 Patients may also be reluctant to engage in therapy.2Source:Stimmel GL. How to counsel patients about depression and its treatment. Pharmacotherapy. 1995;15(6 Pt 2):100S-104S.Hirschfeld RM et al. The National Depressive and Manic-Depressive Association consensus statement on the undertreatment of depression. JAMA. 1997;277(4): Stimmel GL. How to counsel patients about depression and its treatment. Pharmacotherapy. 1995;15(6 Pt 2):100S-104S.Hirschfeld RM et al. The National Depressive and Manic-Depressive Association consensus statement on the undertreatment of depression. JAMA. 1997;277(4):Stimmel GL. How to counsel patients about depression and its treatment. Pharmacotherapy. 1995;15(6 Pt 2):100S-104S.
37 Antidepressant Warnings All patients being treated with antidepressants for any indication should be monitored closely for:Clinical worseningSuicidalityUnusual changes in behaviorMonitor these patients especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases.Antidepressant Use in Children, Adolescents, and Adults
38 Practice Recommendation Base a choice of antidepressant on the patient’s prior response, patient and clinician preference, potential side effects, and cost.Choose any class of antidepressant as a first-line treatment for MDD.Ask patients from different ethnic groups about their treatment preference for MDD.Choosing an antidepressant is more of an art than an exact science. So there is no specific recommendation on the first antidepressant to choose.AAFP Approved source: National Guideline Clearinghouse.
39 MaintenancePatients with one lifetime episode of MDD who achieve remission on antidepressants should continue to take them for another 6 to 12 months.Patients with two or more episodes should be maintained an additional 15 months to 3 years.Patients with chronic MDD or MDD with concurrent dysthymia should be continued on antidepressants an additional 15 to 28 months after the acute phase treatment.Kaiser Permanente Care Management Institute. Depression clinical guidelines.
40 Practice Recommendation Follow up with patients on antidepressants for MDD:At least once within the first monthAt least once more 4 to 8 weeks after the first contactAssess for adherence, side effects, suicidal ideation, and response.AAFP Approved Source: National Guideline Clearinghouse.Strength of evidence: Consensus-based. A practice is recommended based on the consensus or expert opinion of the Guideline Development Team.
41 Practice Recommendation Advise patients that:Most people need to be on antidepressant medication for at least 6 months.It may take 2 to 6 weeks to see any improvement.It is very important to take the medication as prescribed, even after they start feeling better.They should not stop taking the medication without calling the provider first.Changing the dose or dose schedule can help manage side effects.AAFP Approved Source: Institute for Clinical Systems Improvement.
42 Steps for Choosing an Effective Antidepressant Recognize that some antidepressants may be more effective in certain populations even though most are generally of equal effectiveness.Ask about personal or family history of treatment with antidepressants, particularly about side effects.Consider the burden of side effects, particularly weight gain and sexual side effects in midlife women.Consider drug-drug interactions with other medications the patient is taking or may take.Consider the potential lethality of the antidepressant in the case of an overdose.Use antidepressant side effects for efficacy.Moore DP, Jefferson JW. Mood Disorders. In: Moore & Jefferson: Handbook of Medical Psychiatry, 2nd ed. Philadelphia: Mosby; 2004.
43 Treatment Recommendation Base a choice of antidepressant on the patient’s prior response, patient and clinician preference, potential side effects, and cost.AAFP Approved Source: National Guideline Clearinghouse.Strength of evidence: Consensus-based. A practice is recommended based on the consensus or expert opinion of the Guideline Development Team.
44 Follow-Up Considerations In The First Three Months WeekTreatment Actions2Check patient compliance to medication usage. Assess for adherence, side effects, suicidal ideation, and patient response. Adjust, as appropriate, medication and dosage.4Re-check patient compliance to medication usage. Assess for adherence, side effects, suicidal ideation, and patient response.6Adjust, as appropriate, medication and dosage.7 - 12Monthly communication with patient; Patients Appointments every 3rd or 4th week; Further Medication or Medication Dosage Adjustments; Goal: Remission
45 Other Options Include . . . Combine antidepressants and psychotherapy Increase dose of initial antidepressantCombine treatment with SSRI and low-dose desipramine (monitoring for TCA toxicity)Switch to different antidepressant of same or different classAugment with low-dose (300–600 mg/day) lithium in consultation with psychiatristSwitch from psychotherapy to antidepressants, or antidepressants to psychotherapyKaiser Permanente Care Management Institute. Depression clinical practice guidelines. Accessed May 2, 2007.
46 Treatment GoalThe goal of treatment with antidepressant medication in the acute phase is the remission of major depressive disorder symptomsAPA Practice Guidelines for the Treatment of Psychiatric Disorders.
47 Follow Up after Initial Treatment Follow up with patients on antidepressants for MDD:Individualize visit frequency for each patientPatient’s starting or switching to a new RX should be seen every two weeks until stablePatient’s at increased risk for suicidality or self-injury seen more frequentlyContact all patients in early phase of treatment to assess for suicidality or self-injuryAssess response with validated toolTexas Medication Algorithm Project (TMAP) Treatment of Major Depressive Disorder Clinician’s Manual-
48 Maintenance50% of MDD patients will experience recurrence after initial episode without long-term treatment3< episodes – maintain AD therapy as preventativeDuration varies depending on risk factors from 1 year to lifetimeConsider maintenance after 2 episodes for patients with high risk factors, PTSD, co-morbid anxiety, chronic depression or serious personality disorderIncreased stressors may warrant longer maintenanceWeilburg JB, O'Leary KM, Meigs JB, Hennen J, Stafford RS. Evaluation of the adequacy of outpatient antidepressant treatment. Psychiatr Serv. 2003;54(9):Texas Medication Algorithm Project (TMAP) Treatment of Major Depressive Disorder Clinician’s Manual-
49 Continuation bridges remission to recovery Patients who remit should continue RX at least 6-9 months after remission at same dosage at which response was achievedVisits every 3 monthsTexas Medication Algorithm Project (TMAP) Treatment of Major Depressive Disorder Clinician’s Manual-
50 Increasing the Likelihood of Remission Measurement-based careOptimize dose/extend trialSelection of antidepressantRole of adherencePharmacologic adjunctsRole of psychotherapyRush AJ, et al. J Clin Psychiatry ;58(suppl 13):14-22.Thase ME, et al. Am J Psychiatry ;60(suppl 22):3-6.Trivedi M et al. Am J Psychiatry. 2006;163(1):28-40.
51 Adherence to Treatment Having depression generally increases the risk of nonadherence three to four-foldHispanic patients may be less likely to comply with antidepressant treatment than whitesTo improve adherence:Understand the patient’s model of the illnessIdentify social and financial barriers to adherenceAddress patient concerns about the medicationDiscuss patient understanding about treatment and ability to follow through (i.e. health literacy)Lewis-Fernandez R et al; JABEFP; 2005:18; ; Wagner GJ et al. Psychiatr Serv. 1998;49(2):239-40; Harman JS et al. Psychiatr Serv. 2004;55(12): ; Sleath B et al. Compr Psychiatry. 2003;44(3):51
52 If Initial Treatment Ineffective Medication trial should last 8-12 weeksIf no side effects or tolerability issues, increase dosage every 2-3 weeks untilRemission achievedMax dose achievedSide effects limit titrationCombine antidepressants and psychotherapyCombine antidepressants or consider augmentation trialConsidering tailoring your treatment for specific sub- populations (e.g., elderly, midlife women etc).Texas Medication Algorithm Project (TMAP) Treatment of Major Depressive Disorder Clinician’s Manual-Kaiser Permanente Care Management Institute. Depression clinical practice guidelines.
53 Factors that Predispose to Incomplete Remission ChronicityMedical co morbidityOlder ageAxis I or II co morbiditySeverityInadequate treatmentThase ME, et al. Am J Psychiatry ;58(suppl 13):23-29.Nierenberg AA, et al. J Clin Psychiatry ;60(suppl 22):7-11.Thase ME. J Clin Psychiatry ;60(suppl 22):3-6.
54 Consequences of Failing to Achieve Remission Increased risk of relapseContinued psychosocial limitationsContinued impairments at workWorsened prognosis of Axis III disordersIncreased utilization of medical servicesSustained elevation of suicide and substance abuse risksIncreased risk of treatment resistanceNierenberg AA, et al. J Clin Psychiatry ;60(suppl 22):7-11.Thase ME. J Clin Psychiatry ;60(suppl 22):3-6.
55 In-Office Therapeutic Approaches to Management of Depression Supportive Treatment - Identify and reinforce positive behaviors and coping mechanisms that patient has used in the past or is using now“Even though you’ve felt lousy, you have gone to work everyday and done what you need to do. That shows a lot of resilience”.“Let’s think about ways you’ve handled situations like that in the past and see how you can apply those skills you already have”.
56 Aiding the Patient in Problem Solving Problem Solving – Most depressed individuals feel overwhelmed by their emotions and their problems. Help patient identify current psychosocial stressors and help patient formulate coping strategy. Don’t focus on significant interpersonal problems or large life issues.Steps in Problem SolvingIdentify stressors - “What things going on in your life bother you most right now?”Focus on specific behavior – “You told me you feel bad because you can’t get anything done around the house and it is a mess. If you could do one thing around the house to help you feel like you are handling things better, what would you do?”Break behavior down to manageable components – “That huge pile of laundry seems really overwhelming. It would take more energy than you have to do 10 loads of laundry. How about starting by sorting some of it, maybe one basket of laundry. Then tomorrow you may feel like throwing one load in the laundry.”
57 Problem Solving Steps in Problem Solving Cont’d Guarantee success don’t define failure – “It may be difficult to get that load of laundry started. Even talking about it like we are doing and having a plan to get started is a great step. When I see you next week we’ll see how things are going.”Reinforce successive approximations – “Being able to sort that laundry shows you’ve come a long way since I first saw you.”Assess barriers to change – “When you walked into the laundry room and saw the basket of sorted laundry, what do you think kept you from putting it in the washer?”Reframe barriers – “The thought of folding all that laundry seemed like too much. Remember when even the thought of sorting it was overwhelming but then you were able to do that. Maybe folding it while you are watching Desperate Housewives would make it easier.”Reinforce success and apply process to another problem – “Doing the laundry shows that you are really starting to get better. Is there another thing around the house that’s bothering you
58 Helping Patients with Mild Depression SPEAKSchedule – taking control by planning and organizing to counteract avolitional statePleasurable Activities – engaging in one pleasurable activity a day to counteract anhedoniaExercise – increasing activity even slightly increases sense of control and has positive physical benefitsAssertiveness – engaging in small acts that set limits and express own feelings reflects positively on sense of selfKind Thoughts About Oneself – positive self talk can negate effects of negative/irrational self perceptionsJohn Christensen, Ph.D., Oregon Health Sciences University
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