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Diabetes Type II; Obesity; Feedback on Anorexia and Shingles; Lyme Disease

With news that actor Tom Hanks has been diagnosed with type-2 diabetes, how far in advance can doctors predict the onset of the condition, and what can be done to delay it?

With news that actor Tom Hanks has been diagnosed with Type 2 Diabetes, how far in advance can doctors predict the onset of the condition and what can be done to delay it.

And is obesity a disease? It has been classified as such in America, so what are the implications and should the UK follow suit?

Plus the first ever conference on Lyme Disease - the tick borne infection that can cause serious complications.

Available now

28 minutes

Programme Transcript - Inside Health

Downloaded from www.bbc.co.uk/radio4 

THE ATTACHED TRANSCRIPT WAS TYPED FROM A RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT.  BECAUSE OF THE RISK OF MISHEARING AND THE DIFFICULTY IN SOME CASES OF IDENTIFYING INDIVIDUAL SPEAKERS, THE BBC CANNOT VOUCH FOR ITS COMPLETE ACCURACY.

 

 

INSIDE HEALTH

           

Programme 3.

 

TX:  22.10.13  2100-2130

 

PRESENTER:  MARK PORTER

 

PRODUCER:  ERIKA WRIGHT

 

 

Porter

Coming up in today’s programme:  Tackling obesity: Don’t be nasty to overweight people was how the media summarised last week’s draft guidance from NICE on shrinking the nation’s growing waistband.  We debate whether classifying obesity as a disease is likely to be a help, or a hindrance?

 

And I visit Public Health England’s first ever conference on Lyme Disease for an update on the latest thinking on the diagnosis and treatment of this tick borne infection.

 

But first Tom Hanks’ revelation that he has Type 2 diabetes. In itself, not that unusual - at least two million people are currently thought to have the condition in the UK.  No, what caught our attention here at Inside Health was the actor’s admission that his doctor had been monitoring him for many years, and that he had graduated from having high normal blood sugar levels to full blown diabetes. So can doctors predict who is going to develop the condition long before they do?

 

Dr Stephen Lawrence is a GP and Primary Care Medical Advisor for Diabetes UK and he’s on the line from his surgery in Kent.

 

Dr Lawrence, is there such a thing as a pre-diabetic state?

 

Lawrence

That’s a very interesting question.  There are in the region of around seven million people in the UK who are potentially pre-diabetic – that is at risk of diabetes – and this is exemplified by the fact that they perhaps carry around a lot more weight around the midriff than would be expected and also if you were to check their glucose levels you may find that they fall within a group that is whilst it isn’t diabetes it certainly isn’t within the normal range.

 

Porter

Because it might come as a surprise to a lot of people who think you’ve either got diabetes or you haven’t but what you’re saying, effectively, there’s a sort of grey area in between.  Do we know that these people who are lying twixt normality and confirmed diabetes, do we know that they’re more likely to go on to develop the condition and if so over what sort of time period?

 

Lawrence

We certainly have evidence that if you were to take someone who has an abnormal glucose regulation then over a 15 year period half of these people will go on to develop diabetes but we also are aware through many, many studies that you can reduce your risk of developing diabetes, if you fall within this state, by up to 58% by simply making lifestyle changes.  And this involves just a very modest loss in weight, amounting to between five and 10%.

 

Porter

So we could be using readings that we get back in this intermediate, if you like, pre-diabetic phase, we could be using that as educational tools for our patients, saying look you’re not in trouble yet but you may well be in the future, let’s do something about it?

 

Lawrence

Absolutely and it really is a fantastic opportunity to significantly impact on someone’s future risk.

 

Porter

We should be clear at this stage that we’re talking here about the more common Type 2 diabetes that tends to develop later in life, rather than the more rapid onset Type1 – they’re very different conditions.  What happens if you cross this threshold and go into the realms where you’re actually confirmed as having diabetes, can you go back again?

 

Lawrence

Up until approximately two years ago the answer to that would have been no but a very important piece of work was done in Newcastle two years ago, in a very small study, there were only 11 people in this study, but they managed to reverse their diabetes by very drastically cutting their food intake.  Now I should add for listeners that this was really quite an extreme reduction in calorie intake to just 600 calories daily for a two month period.  Now in this group seven out of the 11 actually remitted their diabetes, we tend to say remit rather than completely cured because clearly those that regained the weight regained their diabetes.

 

Porter

Dr Stephen Lawrence, thank you very much.

 

And that research in Newcastle using low calorie diets to reverse diabetes is ongoing and now includes 140 people in the study.

 

Well as you’ve just heard Type 2 diabetes is closely linked to weight gain but while diabetes is a disease, obesity isn’t – at least not in most people’s books. The American Medical Association thinks differently and, earlier this year - and somewhat controversially - re-classified obesity as a disease.

 

A step in the right direction, or a step too far?

 

To discuss the implications I am joined by Inside Health’s Margaret McCartney, the Editor of the Drugs and Therapeutics Bulletin James Cave, and Professor Nick Finer, a specialist in obesity at University College Hospital, London.

 

Nick Finer, the American Medical Association’s stance, is it right?

 

Finer

Absolutely, I mean disease, it’s clear what obesity is – it’s a disorder of the body, there are characteristic symptoms and signs and indeed it’s been recognised for a long time in the international classification of diseases there are now about 12 codes for obesity.  So my view – semantically there’s no argument, clinically it clearly is a disease – it causes ill health, distress and other diseases.

 

Porter

James Cave, I presume that the one group that would welcome such a classification would be the pharmaceutical industry, if you have a disease you need a treatment, and that’s often drugs and – that’s the way we think, isn’t it, in medicine?

 

Cave

Absolutely and I think you’ve got to remember that the question is is it a disease or is it actually a risk factor for other diseases.  And the risk of classifying it as a disease or even perhaps as a number of diseases, as the classification suggests it might be, is that you make a one size fits all.  And the problem about a one size fits all approach is that you miss the issues for individual patients.

 

Porter

Margaret McCartney, you work in general practice and have to deal with the knock on effects of excessive weight gain, obesity, on a daily basis, does it really matter to you whether or not it’s called a disease?

 

McCartney

It does, absolutely does matter and I think there are three major problems for me.  One is, as James says, obesity is a risk factor for ill health, just like ageing, just like high blood pressure, just like cholesterol, all these numbers have a problem in that where does the line get drawn between normal and abnormal.  And in general risk factors are a gift to pharmaceutical industries who want to try and normalise that back down.  The second issue is that when we call obesity a disease we medicalise it, we put it under the control of doctors and I think that’s a bad idea because doctors in fact don’t have a great deal to offer the vast majority of people who are classified in the obese category.  That then leads us into who owns the disease – is it the patient then who owns the disease, a patient who is obese and therefore diseased or is this a societal problem, a problem where economics and political policies collide, where does the solution lie?  And I think the problem is that when we say it’s a medical problem, a disease, we hand over that problem then to doctors to fix and I don’t think doctors can fix it, it’s a far wider issue and problem than that.

 

Porter

Nick Finer, you’ve welcomed the move, how does it help us tackle the problem practically?

 

Finer

The fact is that there are very good treatments and doctors, if they’re properly trained, and dare I say it if they’re properly remunerated, and that’s one of the problems that GPs aren’t paid for treating obesity so they don’t, then actually we have effective treatments.  There are treatments spanning lifestyle interventions which may be delivered by healthcare professionals and may involve doctors, there are actually – there is only one drug at the moment so the argument that this is a sort of a gift to the pharmaceutical industry is a little bit premature and there are surgical solutions.  I don’t disagree that the mechanisms and the causes behind it are driven by society but the advances we’ve had in genetics, we know that there are 31 genes which are susceptibility genes which account for a small but important part of obesity.  We know that there are people who have one mutation of a gene and inevitably become obese – what more do you want?

 

McCartney

Can I just come in about this idea that we have effective solutions that work in primary care?  There are some interventions that make some difference but in actual fact commercial weight loss programmes are just about as good as anything we have to offer and they don’t involve doctors at all.  What a lot of the studies are missing are what are the long term solutions for weight loss and in actual fact most of the “solutions” that we have pharmacologically have been shown to be dangerous or haven’t worked in the past.  I would ask again, really and truly, is this the best way to be managing obesity as a risk factor for lots of other diseases?

 

Finer

So you want to wait until the patient has developed their diabetes, diabetes is not a disease by these definitions either…

 

McCartney

That’s not what I’ve said at all.

 

Finer

But that’s what you’re implying to not treat it.  Can I just…

 

McCartney

No I’m not, I’m asking what effective treatment is and…

 

Finer

Well effective treatment is very clear that there are a number – there are, what, eight long term 30 year in some cases trials showing that weight management can halve the development of diabetes over a 20 or 30 year period.  Chinese study; Diabetes Prevention Study; Finnish Diabetes Prevention Study.  The real issue is that I think is that doctors don’t feel that treating overweight and obesity is proper doctoring and that’s what has to change.

 

Porter

We’ve had a similar sort of feeling come from our listeners actually – we’ve had lots of tweets and e-mails on this subject – and there is a general them amongst a lot of the e-mails with people saying look the problem with medicalising this, calling it a disease, is you turn a person into a patient and somehow you abdicate responsibility to the doctor, is that not a concern then – it’s not my fault I’ve got a condition?

 

Finer

No, no, look the question I suppose is can doctors by treating overweight and obesity improve quality of life, can they prevent other diseases, can they lengthen life and prevent premature loss of life and the answer to all of those is very strongly yes it is.  And I think therefore doctors do need to get involved.  Of course I would love to see our society nannied and manipulated to make it much harder for people to become overweight and obese but to say to people it is just your own fault.  People who are short of breath are not told to breathe more.

 

McCartney

I don’t think that’s what one says at all to a person who’s obese or overweight if you’re trying to de-medicalise the condition.  And no way are you saying to that person it is your fault.  In the meantime in terms of looking at public health risks the food and drink industry have been let off very lightly – it’s all voluntary arrangements about food labelling and things like that.  Really and truly is this the way we want to go where we’re putting it down to individual patients and doctors to do this work or are we going to help people?

 

Porter

Well we’re talking about our role within the medical profession in tackling this problem and at the moment there’s a fair criticism that we’re not doing enough, now that might be because we don’t have enough tools in terms of – our conventional medical tools but if we’re not doing enough surely James if we make this a disease it will move it higher up the priority, doesn’t mean we have to resort to the prescription pad.

 

Cave

I think you’re right and I think the one – the one area I do think that there’s some traction with the idea of calling it a diagnosis it does give permissions sometimes for doctors to say well actually it’s part of my role to help this patient.  But I still think the risk is there are unexpected consequences of doing this and they are particularly the case for obesity because it is so commonly…

 

Porter

And by unintended consequences I mean what’s the downside here, what’s the worst thing that could happen?

 

Cave

Well I think the unexpected consequences are one, as Margaret has said, we move the focus away from society or the environment we live in to the person, so we start saying it’s your problem, so in areas where you have this environment which is full of calories you’re going to see more obesity.  And I think that there are parallels here – in 1952 we had people dying in London from the smog, now what we had to do was get rid of the smog, not say to these people ooh it’s your chest, you’ve got a chest problem, we’ll call it – we’ll make it a diagnosis.  We got rid of the smog.

 

Finer

That is what’s called public health.  Let’s take typhoid as an example, that was a societal disease because we didn’t have decent sanitation, we didn’t say to people oh well I’m sorry typhoid’s not really a disease because it’s a public health issue.  I mean I don’t understand this lack of a desire to actually care for people who have…..no, no, I’m sorry, I think this is what doctors and healthcare professionals do.  What they tend not to do is to treat non-diseases.  And I think until we can get the medical profession to actually recognise the importance of obesity….. I see everyday people who have been diagnosed as having obstructive sleep apnoea, they have to have a machine to help them keep breathing at night, their diagnosis is obesity but yet they can have all the medical panoply, equipment, expensive things to keep them breathing, nobody has made the diagnosis that it is obesity and it is a treatable disease.

 

Cave

My concern is that if we had the typhoid epidemics in London today that we had when Dr Snow put the lock round the old pump we’d have treatments going out, drugs being dished out by this government to treat all these cases, we wouldn’t have a public health approach.  And I think this is exactly the problem have, we have at the moment this drive towards let’s look – let’s find the drugs for this awful condition called obesity when actually the public health issues are staring us in the face.

 

Finer

They’re not mutually exclusive, what I’m saying is until governments, you, me come up with the public health solutions we have morbidity, we have premature mortality, the same loss of life as cigarette smoking, we need to actually provide care.

 

McCartney

The problem that many people have when they are obese and need to lose weight is that it’s not only difficult to do but it’s difficult to sustain.  And I think the problem is that no matter how committed and how able people are when they get involved with losing weight it can be very difficult in the medium to longer term to keep that weight off.  And we live in a society that does not prioritise public health, instead the society – instead politics have really handed over the management of weight to doctors and that makes it fundamentally difficult I think for people to keep off weight that they’ve lost in the longer term.  This means I think that we’re almost giving people a second chance to get ill again or to get all the diseases associated with obesity back again because we’re not willing to put our money where our mouth is and I think that we have to think much more seriously about the way that public health is going in this country because at this moment in time we have failed to pass plain packs on cigarettes, we have failed to do anything about alcohol minimum pricing, we have allowed food manufacturers to have voluntary codes on their labels about what the calorific intake of food is.  Is this really the situation that we want because we will fail?

 

Finer

Margaret, I don’t disagree, it is a preventable disease, the question is is if we fail to prevent it, for whatever reasons, I argue it is a disease and that sufferers from it have every entitlement to get medical care like they do for all the other preventable diseases we have.

 

Porter

But can I ask – can I ask you – the three of you here – I mean are you comfortable at the moment with the amount of resource, time and effort we put into stopping people smoking, for instance, compared to that which we offer to help people who’ve got a weight problem?

 

Cave

Well I think the difficulty for me is I’m confused, here I am meant to be editor of a journal and I’m confused because you see I don’t know what to say to an obese patient, I don’t know why they’re obese – there are so many factors…

 

Porter

Well you might not know why someone smokes or drinks too much but you would still tackle the issue wouldn’t you?

 

Cave

Well exactly and the point about this is that we haven’t called smoking a disease, we’ve just got on and tackled it.

 

Finer

But you prescribe for it.

 

Cave

Well actually I haven’t prescribed very much for it because a lot of the studies on the drugs were not great and actually there are various different ways.  But the point about this is that obesity is such a multifactorial risk factor, there’s so many issues that to make a one size fits all is not going to help the patient in front of me on a Monday morning who’s obese, who’s probably come in because they’ve sprained their ankle and twisted it and the last thing they want to hear from me is me saying well of course what do you expect, you’re obese – they want their ankle sorted out actually.  And then you try and access – is there an issue about your weight – you try and see if you can start a dialogue with patients and they will turn round to you and give you any number of reasons why they are who they are – it’s their big bones or they’ve listened to a professor who told them it’s all in their genes.  And people find excuses and reasons and everyone I’ve seen I think is different.

 

Finer

Look there are very good evidence based guidelines – NICE looked at this, Scottish Intercollegiate guidelines have looked at it – the problem is we’re not even implementing those guidelines.  And I think that the root cause of it is that actually healthcare professionals - doctors, nurses - feel inadequate.  The point that you make about the person coming in with a sprained ankle – that is a missed opportunity for health promotion, if you are not prepared to tackle…. wait till they get diabetes, wait till they get sleep apnoea, wait till they’ve had their heart attack?  You’re missing a health promotional opportunity.

 

McCartney

Well can I just say in answer to that I’m aware of patients who had that kind of missed opportunity met when they came in with their sore ankle and they were so embarrassed, humiliated and ashamed by the doctor’s seemingly good intentions that they never come back for years and year to see the doctor.  So having this kind of prescription that we’ve got all these opportunities to make all the time…

 

Porter

But Margaret may I play devil’s advocate here because you get paid, I get paid, to ask patients whether they smoke and to record the result and it wouldn’t stop you asking about their smoking would it?

 

McCartney

I feel guilty – no I feel guilty about that all the time but at least there is some evidence that if you prompt someone to consider stopping smoking that will make a difference, you can increase the percentage by a small amount of quit rate, so there is some evidence for that.

 

Porter

But should we not be doing the same with obesity Nick, is there evidence to support that?

 

McCartney

No there isn’t evidence but opportunistic interventions that make a difference in the long term, now you can talk about the short term and the medium term but in the long term you’re not and I think that the more we say this is all down to doctors or GPs inadequacy – I mean I’m sure I am inadequate in many ways – but what we’re really doing is we’re saying this is the doctors to sort this out and therefore we’re giving the politicians an opportunity to say we just need to put this into [indistinct word], we just need to pay GPs to do this more.  That is not going to sort this out and I think that if we believe that it does we’re doing our patients a disservice and it really is not caring about them.

 

Finer

Doctors can’t solve the problem but they can actually address the needs of their patients.

 

Porter

Nick Finer, James Cave and Margaret McCartney – I suspect this is a debate that will run and run but we must leave it there, thank you very much.

 

Now time for some listener feedback on the issues we have covered so far in the series. Charlotte Bevan, a parent advocate for children with eating disorders, liked our item on anorexia – particularly the interview with Professor Bryan Lask.  And she passed the message on.

 

Bevan

The next morning I blogged it and spread it on Facebook, Twitter, across social media and we had an amazing reaction from across the world – from patients, from parents, from others in the eating disorder world, everyone was debating it, everyone was listening to it.  It was a very, very good piece.   I haven’t seen a reaction like that for a very long time and even people who slightly disagreed with Professor Lask were very eager to engage in debate and talk about it.  Parents certainly were thrilled that someone so eminent had come out and exonerated them saying there was no evidence that parents caused eating disorders, so I ran round my bedroom whooping.  The best comment I think was from an ex-patient of his who said I hated him when he was making me eat but I love him now I’m better.

 

Porter

Charlotte Bevan President of the newly formed Bryan Lask Appreciation Society.

 

Anne Randall e-mailed in after our item on the shingles vaccine.

 

“I am puzzled”, she writes, “how does the vaccine actually work given that shingles is caused by the reactivation of dormant chickenpox virus hiding in the spine?”

 

Good question Anne. The reason the chickenpox virus re-emerges as shingles later in life is because the individual’s immunity to it has waned over the years. The vaccine gives that waning immunity a boost preventing the re-emergence of the virus. So you still have the chickenpox lying dormant inside you but it just won’t come back as shingles.

 

Please do get in touch if there is a health issue that is confusing you – you can e-mail me via insidehealth@bbc.co.uk or send a tweet to @bbcradio4 including the hashtag insidehealth. 

 

The NHS has received a lot of criticism in recent years over the services it offers for Lyme Disease – a condition caused by a bacterium spread through tick bites.

 

Symptoms include a flu-like illness and a spreading circular skin rash, both of which typically develop within three to four weeks of being bitten.  The infection responds well to prompt diagnosis and treatment with antibiotics, but if it is missed and left untreated – as it often is - then it can lead to long term complications including heart problems, nerve damage and arthritis. And the management of this chronic form generates most of the controversy that surrounds the condition.

 

Public Health England has risen to the challenge by convening the UK’s first medical conference dedicated to Lyme Disease, and I went along to catch up with one of the keynote speakers. 

 

Consultant Microbiologist Matt Dryden is a specialist in Infection, Rare and Imported Pathogens at Public Health England and runs a Lyme Disease clinic in Winchester – not far from the New Forest, one of the UK hotspots for the disease.

 

Dryden

It’s a controversial disease because patients who present with objective clinical signs, in other words ones that doctors can recognise – a skin rash, specific neurological problems – are easy to make a clinical diagnosis for.  And if you do a blood test with those they’re often positive.  So you’ve got all the features – the diagnostic features – that patients had a tick bite, they’ve got an objective clinical site and they’ve got a positive blood tests – that’s a clear diagnosis of Lyme Disease.  Then you’ve got a group of patients who don’t fit into that category at all, they often retrospectively think ooh I might have been bitten by a tick, sometime in the past, I’m not feeling very well at the moment because I’ve got muscle aches, headaches, I’m tired all the time and I’ve looked it up on the internet and my goodness all those symptoms fit in with Lyme Disease, I must have Lyme Disease.  So a lot of people make a self-diagnosis or a friend suggests it, they then go along and have a test which is negative or more confusingly sometimes is indeterminate and then they believe they have chronic Lyme.  And we, as doctors, often see patients with unclear clinical signs and we always give the patient the benefit of the doubt and will treat those.  We’re not relying on a test to treat or not treat a patient, we use our clinical acumen to decide whether they need treating.  But what’s clear is that long term antibiotics don’t make patients any better and so this syndrome of chronic illness is not necessarily associated with Lyme and probably is only associated with Lyme in a very small number of cases, there are lots of other illnesses that produce exactly the same symptoms.  But those are the groups of patients we really need more research on.  They get frustrated because doctors can never get to the bottom of their problem and the tests don’t seem to tell them one way or the other in black and white what their underlying illness is.

 

Porter

And have you ever seen anybody that you made the diagnosis in, that you’ve given the treatment to that they haven’t got better?

 

Dryden

No.  So where we have diagnosed Lyme Disease categorically they have all responded to short course antibiotics including one patient who had a lesion within his spinal cord that was initially diagnosed as a tumour, he was effectively given a death sentence because it was so high up in the spinal cord and he started booking his own funeral.  We made the diagnosis of Lyme Disease shortly after that, he responded very quickly to antibiotics and has remained well ever since.

 

Porter

So Matt, in your experience, everybody who’s got long term symptoms as a result of Lyme Disease has a positive Lyme test and all of those that you’ve treated with the antibiotics, short course of antibiotics, have got better, so it would suggest that people with negative tests and symptoms that haven’t responded to Lyme Disease have probably got something else – is that what you’re saying?

 

Dryden

That is what I’m saying yes.  I think patients with chronic symptoms and negative tests – there are several possible deferential diagnoses – it could be a post-infectious problem so the immune system is jiggled up if you like and is causing these chronic symptoms; it could be another infection by a bug we don’t know anything about and we need to do research on that; it could be another illness, it could be a neurological condition.

 

Porter

Because there is a school of thought amongst some clinicians, I mean I hear about patients of mine who’ve been to clinics in Germany, for instance, where they’ve been visiting regularly having ongoing treatment for Lyme Disease as if it’s something they have to have year in year out – what’s your view on that?

 

Dryden

My view is that that’s entirely unnecessary.

 

Porter

Well listening to that is Sandra Pearson, who’s medical director for Lyme Disease Action and she joins me now down the line from Plymouth.

 

Would you agree with that?

 

Pearson

No I wouldn’t agree with all of it.  The issue often isn’t so clear cut and sometimes tests need very careful interpretation and further tests of specific tissues may need to be looked at.  I think there is a tendency to over-simplify and to foreclose on what are now known uncertainties and limitations..  Public Health England are beginning to appreciate that there are grey areas and acknowledge that there are grey areas and that any clinical diagnosis needs to take into account a careful history from the patient, possibly the carer or physical signs and for any test results to be interpreted really very carefully.

 

Porter

And Matt Dryden did allude to that, I mean he said that doctors can use their discretion, so if there’s a good story suggestive of Lyme Disease and the test is equivocal or negative you can still give the treatment.  What’s your take on the effectiveness of the treatment?  If somebody is given a proper short course of antibiotics is it your impression that that will work in nearly all cases?

 

Pearson

We actually don’t know.  The impression from reading the literature is that early treatment is likely to be more effective.  The main area of uncertainties are about people who are diagnosed late, people may be who have a very short course of treatment – 14 or 21 days – and then appear to relapse objectively; people who perhaps have treatment and then are left with residual symptoms afterwards.  We don’t know whether that is due to persisting infection or whether they’ve got some other form of tick borne infection perhaps in addition to Lyme.  And actually nobody knows, that’s where the outer limit of medicine and science is at the moment with regard to Lyme.  The problem is that historically there has been a foreclosure on uncertainties, there is a culture within the NHS in England of adopting false certainty but then patients have the lived experience of Lyme.  And I’m not talking about patients with a few vague aches and pains, our help desk is dealing with people with severe neurological problems, clear history of tick bite, rash but because the test perhaps is not 100% clear cut there is this area of doubt.  And I’m really pleased to hear Matt Dryden say that patients will be given the benefit of the doubt, sometimes it’s just not possible to be 100% certain.

 

Porter

Dr Sandra Pearson.  And you’ll find some useful links on Lyme disease on the Inside Health page of the Radio 4 website.

 

Just time to tell you about next week’s programme when I will be meeting a doctor who is hoping to harness technology to make it easier to get in to see your GP. And fungal nail infections - I am sure you have all seen those ads showing thickened, yellow toe nails, but what’s the best way to deal with them?  Join me next week to find out.

 

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