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Friday, April 2, 2010

Medication overuse headaches, Living Without Pain and how Neuromuscular Dentistry Can Help Change Lives

It is an intresthing phenomenon that medication overuse headaches are an enormous problem in neuromuscular dentistry even though most neuromuscular dentists use very little medication. By the time patients have been seen by a neuromuscular dentist they have frequently seen numerous physicians and other medical specialists and are using multiple perscription and over the counter medications.

Breaking the cycle of medication overuse headache by STEWART J. TEPPER, MD in the Cleveland Clinic Journal of Medicine reported:

"(Abstract) When patients who have frequent, disabling migraines take medications to relieve their symptoms, they run the risk that the attacks will increase in frequency to daily or near-daily as a rebound effect comes into play. This pattern, called medication overuse headache, is more likely to happen with butalbital and opioids than with migraine-specific drugs, as partial responses lead to recurrence, repeat dosing, and, eventually, overuse. Breaking the cycle involves weaning the patient from the overused medications, setting up a preventive regimen, and setting strict limits on the use of medications to relieve acute symptoms."

Medication overuse headaches are a frequent event with neuromuscular problems that frequently caue chronic daily tension headaches. These medications to not correct the underlying problem and the paient now has a layer cake of headaches that are often frosted with vascular headaches. The tirgeminal nervous system and the related trigeminovascular system is primarily responsible for the majority of headaches. I frequently find weaning my patients off narcotic and pschoactive medications is much harder than eliminating their pain. This is especially true because I advise patients to follow their physicians guidance when weaning off medication. Physicians who have heavily prescribe drugs are not always the best influence to convince patients that overuse headaches are a problem.

Many patients who suffer from medication overuse headaches originally had either migraines, tension-type headaches or a combination of headaches. They frequently also have anxiety and depression as comorbidities. Chronic daily headaches usualy is defined by 3 months with over 15 days/month of headaches that last 4 or more hours if not treated with medication.

According to Dr Tepper "In a large population-based study,3 2.5% of patients who began with episodic migraine (headaches on fewer than 15 days per month) had “transformed migraine” (headaches on 15 or more days per month) 1 year later. The prevalence of chronic daily headache is almost 5% of the general population and may account for up to 70% of the initial diagnoses seen in headache centers." This is what I would call iatrogenic medicine where the treatment of episodic migraine can result in the development of transformed migraine. What is probably more common is that patients with headaches due to nociceptive trigeminal impulses which create migraine and Episoic Tension-Type Headaches are treated with medication rather than correction of the root causes of the headache.

Treatment of headaches must always consider the time of day when headaches occur. Morning headaches are almost universally a result of sleep apnea and/or trigeminal headaches as a result of TMJ disorders and clenching, grinding or other parafunction. The NHLBI considers sleep apnea to be a TMJ disorder so almost 100% of morning headaches are related to abnormal jaw and trigeminal nervous system input.

Denture Patients with morning headachjes represent a special population that may have an easy solution. Historically, dentists have told patients to sleep with their dentures out. this has been shown to cause drastic increases in sleep apnea (and probably morning headaches). Wearing dentures may not only relieve headaches, neck pain and sleep apnea but also help avoid heart attacks, strokes and memory loss. Denture patients with chronic head and neck pain should seek out a neuromuscular dentist who can idealize the physiology of the masticatory system. When patients wear dentures to long without replacement or refitting they may be prone to neck pain and cervicogenic headaches due to changes in head posture.

Dr Tepper describes medication overuse headaches as follow: "Medication overuse headache is a subset of chronic daily headache, also occurring on 15 or more days per month but with the added criterion of medication overuse, ie, regular overuse for more than 3 months of at least one acute treatment drug:
Ergotamine, triptans, opioids, or combination analgesic medications on 10 or more days per month on a regular basis for more than 3 months, or

Simple analgesics or any combination of ergotamine, triptans, analgesics, or opioids on 15 or more days per month on a regular basis for more than 3 months without overuse of any single class alone.

Another criterion is that the patient’s headaches must worsen in some way (usually frequency) as the use of acute medications becomes more frequent.

Medication overuse headache is the most common form of secondary chronic daily headache seen in headache practice, and probably accounts for about half of cases of chronic daily headache."

His article states that this is the most common form of secondary chronic daily headaches. An iatrogenic disorder is one that is caused by the medical treatment. Secondary headaches from meication overuse are definitely iatrogenid and are frequently accompanied by other iatrogenic problems such as bleeding ulcers, narcotic addictions and numerous medication side effects.

THERE ARE TIMES WHEN IT IS ABSOLUTELY NECESSARY TO CONTROL SEVERE PAIN WITH HEAVY DOSES OF MEDICATION. IT IS NOT ACCEPTABLE THAT CORRECTION OF THE UNDERLYING CONDITIONS THAT MAKE PATIENTS REQUIRE THESE DRUGS ARE NOT ADDRESSED. A PREVIOUS POST DISCUSSED IDENTIFICATION OF MYOFASCIAL TRIGGER POINTS VASTLY IMPOVING MIGRAINE TREATMENT SUCCESS.

NEUROMUSCULAR DENTISTS ARE A VALUABLE ASSET TO ALL HEADACHE PATIENTS. Many neurologists are not familiar with the science(http://www.sleepandhealth.com/neuromuscular-dentistry) behind Neuromuscular Dentistry. An excellent approach for all patients with any type of chronic migraine or tension headache to utilize a neuromuscular diagnostic orthotic for a period of about 6 -12 weeks. A neuromuscular orthotic must be worn 24 hours/day and seven days a week and therefore must be comfortable for normal daily life functions.

Most patients respond amazingly well to the diagnostic orthotic and it is rare to not see a minimum of 50% improvement in chronic daily and tension type headaches. Patients with migraines associated with ovulation and/or menstrual cycle may still have exaccerbations during those times. Patients should continue to avoid known headache triggers.

Cervicogenic headaches also respond to neuromuscular dentistry due to changes in forward head posture that gradually occur while wearing the diagnostic orthotic. As the body posture corrects it is frequently necessary to reshape and resurface the diagnostic orthotic over time. I usually start with adjustments one time a week and gradually increase the time between visits. Each patient is unique and some patients need more frequent adjustments. Other patients have "miracle relief" with complete elimination of all migraine and muscle pain after the first visit. Often the "miracle relief" patient is not cured but just has so much relief and never felt so good that they report complete relief. When they get used to this new feeling (not having pain is often a totally new sensation) there are often still residual problems to address.

Patients discuss feeling a lightness or sense of energy because they are no longer utilizing so many physiologic and psychologic processes to cover up the pain and cope.

I often find that a few visits into treatment I "meet the paient for the first time" because they have changed in dramatic ways that are far more complex than presence of absence of pain. There is a "lightness to their soul" or a new hope not of pain relief but of resuming their life. One patient described her orthotic as ending "Life Interruptess" and I have had spouses tell me that they have rediscovered the person who was lost in a sea of pai.

This does not always translate into total cures, frequently a patient in constant pain for years findsa large bulk of pain gone and they can then begin the process of solving remaining problems that are now discrete entities. Prior, when drowning in pain they could not see the forest for the trees. As overall pain relief occurs they can now actually have proper diagnosis of other problems.

Depression and pschological disorders frequently disappear. I describe as the difference between psychosomatic pain and Somatophsycic pai.

In simplest terms psychosomtic pain translates into "I HURT BECAUSE I'M CRAZY" while Somatopsychic pain translates into "MY PAIN IS MAKING ME CRAZY". Relieve the pain and the "CRAZY" is gone. It is normal to be depressed when you are in constant pain, in fact, "IF YOU ARE IN CONSTANT TERRIBLE PAIN AND DO NOT BECOME DEPRESSED YOU ARE CERTIFIABLE" Depression is a normal outcome of chronic pain.

There is no true cure for long term pain because the pain has changed your past, who you were and what you did. Relief of pain lets you move forward without the weight of a 1000 pound albatross around your neck but the only true cure would be " A DO-OVER ON THE YEARS WHERE CHRONIC PAIN RULED YOUR LIFE" and unfortunately no one can roll back the clock and make you the person you would have been without your pain.

Dr Tepper discusses the many names given to these medication overuse headaches in his article: "Many terms have been used to describe medication overuse headache in the past, such as analgesic-rebound headache (or just rebound headache), transformed migraine with medication overuse, and even chronic migraine. The lack of uniformity in terminology makes for confusion in the literature and difficulty in communicating with patients and colleagues. Some authors mean medication overuse headache when they say chronic daily headache." He spells out why so many patients cannot find answers to their problems. Clearly identifying both the cause and the symptoms is vital in treatment. A essential element in identifying the cause is ruling out other causes. This is why a neuromuscular dental orthotic is so vital not just for treatment but as an essential element of the diagnostic protocol.

Dr Tepper goes on to state: "Complicating this diagnostic confusion is a debate as to whether chronic daily headache in general should be treated as a primary or secondary headache disorder." THIS IS EXTREMELY IMPORTANT! IF WE ARE NOT CLEAR IF WE ARE TREATING THE UNDERLYING CONDITION OR THE IATROGENIC SYMPTOMS OR MEDICATION OVERUSE, MORE HARM CAN BE DONE TO THE PATIENT. ACCORDING TO DR TEPPER " Some European headache specialists insist on a strict division between primary and secondary daily headaches, and medication overuse headache is one of the latter. Many American specialists believe that chronic daily headache is a collective description or phenotype rather than a diagnostic category, and that it is usually associated with and exacerbated by medication overuse. The International Classification of Headache Disorders uses the term “chronic migraine” for primary daily headache, and “medication overuse headache” for secondary daily headache or rebound." THIS LACK OF CLARITY IN DIAGNOSIS IS A MAJOR FAULT IN TREATMENT OF CHRONIC DAILY HEADACHE.

It is important to remember that the meication is used primarily to alter changes caused by the trigeminovascular system. The easies and safest method of altering the Trigeminal nervous system is thru altering afferent impulses that create noxious results. The NTI-TSS appliance is considered an extremely effective, if not most effective migraine treatment. Unfortunately is may complicate achieving a long-term health position. I frequently will use the NTI or a version of it in nocturnal (night-time) appliances but find that for patients looking for long -term complete relief have better results with neuromuscular orthotics. It is postulated that part of the effect of the NTI is on sleep apnea by increasing tongue space and reducing apnea. It is well known that when patients have apneic eventsthat result in changes in sleep stage clenching frequently results. When patients with sleep apnea are treated via Dental Sleep Medicine (http://www.ihatecpap.com) complete or partial headache and migraine relief is frequently reported.

Central Sensitization is a major factor in acute problems becoming chronic and in the development of RSD or CRPS. According to Dr Tepper "Complicating the dilemma, acute migraine-specific medications such as triptans and dihydroergotamine (Migranal) work better when taken early in migraine attacks, before central sensitization and allodynia develop with attendant photophonophobia and sensitivity to other stimuli. On the other hand, overuse will lead to medication overuse headache."

The use of Neuromuscular Dentistry can help prevent central sensitization and even reduce the changes caused by neural plasticity. Central sensitization or changes to the CNS may be reversible if noxious input to the system is reduced. This is the same whether using NTI-TSS or Neuromuscular Orthotics. The difference is NTI uses a new pathological input to turn off or overide a more powerful noxious input whereas a neuromuscular orthotic is used to reduce all noxious input and to return to a normal physiologic state. When sleep apnea is present it is advisable to treat daytime and nightime conditions with distinct appliances.

The next section of Dr Tepper's article I have some points of Disagreement and I will use all capitals for my comments.

"SYMPTOMS VARY (from article)

The symptoms of medication overuse headache vary in frequency, severity, location, quality, and associated features, both among patients and in the same patient. This is because the disease itself varies and also because of differences in the type and frequency of medication intake. Still, some features help to define this problem, and failing to recognize them may account for a widely held clinical feeling that these patients are “difficult.” THIS WIDE VARIETY OF PROBLEMS WILL FAIL TO SEPERATE PRIMARY FROM SECONDARY HEADACHES.

History of episodic migraine. Generally, medication overuse headache does not occur in nonmigraineurs. THE ACTUAL DIAGNOSIS OF MIGRAINE IS FREQUENTLY SUSPECT AND CHRONIC USE OF DRUGS LIKE EXCEDRIN FREQUENTLY OCCURS IN PATIENTS WITH TMD, CERVICAL PAIN AND MUSCULAR TENSION-TYPE HEADACHES.

Headache on most days of the month. Whenever a migraineur starts having headaches on more days than not, the diagnosis of medication overuse should be considered. REMEMBER THERE CAN BE MIGRAINES MIXED WITH TENSION TYPE HEADACHES AND FREQUENTLY THEY BLEND TOGETHER IN THE PATIENTS MIND AS MORE SEVERE AND LESS SEVER MIGRAINE WHEN IN REALITY THEY HAVE TENSION-TYPE HEADACHES OR TMD HEADCHES WITH PERIODIC MIGRAINE.

Overuse of acute medications. The criteria (see above) allow for combining days of acute medication use. For example, if a patient takes a combination analgesic on 5 days and a triptan on 5 different days, that would still be enough days of acute treatment to trigger medication overuse headache.

Variable pain location (THIS IS ALSO CONSISTENT WITH TMD OR MYOFASCIAL PAIN) is a particular characteristic of medication overuse headache. Although the location may differ from day to day (front or back, rostral or caudal, unilateral or bilateral), it is the quantity not the quality or location of the headaches that suggests the diagnosis.

A drug-dependent rhythm. Predictably, the headaches come on in the early morning or awaken the patient from sleep. This may be due to variable drug withdrawal. AS DISCUSSED PREVIOUSLY TMD AND SLEEP APNEA ARE THE PRIMARY CAUSES OF MORNING HEADACHES.

Neck pain. Medication overuse headache frequently involves the neck, and patients often seek and receive treatments such as muscle relaxants or injections to the neck. When patients are weaned from their acute migraine medications, neck pain generally dissipates. The neck pain, however, can recur episodically with their remaining, now-episodic acute migraines. Neck pain associated with medication overuse headache is not usually a sign of a primary neck disorder; rather, it is a symptom of medication overuse headache itself. NEUROLOGISTS FREQUENTLY DO NOT CONSIDER MANUAL OR ANATOMICAL CAUSES OF NECK PAIN IN RELATION TO HEADACHES. PATIENTS WHO ARE OVERCLOSED TEND TO HAVE FORWARD HEAD POSITION THAT CAUSES NECK PAIN AND CERVICOGENIC HEADACHES. THE QUADRANT THEOREM OF GUZAY EXPLAINS WHY THIS HAPPENS. ROCOBADO HAS SHOWN THAT EVERY CM OF FORWARD HEAD POSTURE REQUIRES TWICE THE EFFORT TO MAINTAIN POSTURE. A TWO INCH FORWARD HEAD POSTURE WOULD RESULT IN 3200% INCREASE IN TONIC MUSCLE ACTIVITY TO LOW BACK.

Concomitant depression and anxiety are comorbid with episodic migraine, but appear to be more common with medication overuse headache. Treating the depression or anxiety does not restore an episodic pattern of migraine; weaning from the overused medications remains the most important intervention. A frequent clinical error is to diagnose and treat the psychiatric issues without recognizing medication overuse as the primary problem. A FREQUENT PROBLEM IS WHEN ONE ASSUMES THE DEPRESSION IS THE CAUSE OF PAIN INSTEAD A SECONDARY RESULT OF PAIN. SLEEP DISTURBANCES ASSOCIATED WITH DEPRESSION CAN CERTAINLY INCREASE BOTH MUSCLE PAIN AND HEADACHES. DEPRESION IS FREQUENTLY SEEN WITH UNDIAGNOSED SLEEP APNEA.

Nonrestorative sleep is almost always reported by patients with medication overuse headache. This is often due to the caffeine contained in combination analgesics or to excessive dietary caffeine intake, but it may also be part of the daily acute drug withdrawal syndrome. The sleep problems are also associated with the concomitant depression. Sleep often improves after weaning from the offending substance or substances. As with neck pain, patients do not have a primary sleep disorder—the sleep disturbance is a symptom of medication overuse headache. MANY OF THESE PATIENTS, ESPECIALLY WOMEN DO HAVE AN UNDERLYING SLEEP DISORDER, UARS OR UPPER AIRWAY RESISTAANCE SYNDROME BUT IT DOES NOT MEET THE DIAGNOSTIC CRITERIA TO BE CONSIDERD SLEEP APNEA SYNDROME. THE DEFINITIONS FOR APNEA WERE DEVELOPED ON OLD FAT MEN AND TEND TO UNDERSCORE OF MISS THE DIAGNOOSIS IN FEMALES AND YOUNGER THINNER HEALTHIER PATIENTS IN GENERAL.

ALPHA-INTRUSION INTO DELTA SLEEP IS THE MARKER FOR FIBROMYALGIA BUT IS ALSO FREQUENTLY SEEN WITH TMD DUE TO AIRWAY PROBLEMS.

Vasomotor instability. Autonomic features are commonly associated with medication overuse headache. Rhinorrhea, nasal stuffiness, and lacrimation are features of medication withdrawal, especially from opioids, and are frequently attributed to sinus disease or “sinus headaches.” Many patients undergo unnecessary sinus procedures or are given antibiotics, decongestants, and other wrong medications for incorrect diagnoses. Decongestants can cause and exacerbate medication overuse headache, so they need to be withdrawn. The sinus features generally remit when the overused migraine medications are eliminated. MANY OF THESE PROBLEMS ARE RELATED TO THE NASAL CYCLE AND THE SWITCHING OF SYMPATHETIC AND PARASYMPATHETIC PROCESSES THAT OCCUR ON A REGULAR BASIS AT NIGHT. THERE IS AN EXCELLENT ARTICLE THAT DESCRIBES SOME OF THESE PROCESSES AT: http://www.cnsspectrums.com/aspx/articledetail.aspx?articleid=1163 THESE SYMPTOMS MAY BE MORE RELATED TO A NORMAL PHYSIOLOGIC PROCESS AND ACTUALLY SERVE AS A CUASE OF MEDICATION OVERUSE.

Preventive medications are less effective or ineffective until the acute medications are withdrawn. Thus, prescribing prevention without weaning is usually futile, and the patients are often dismissed as having a refractory problem. At the same time, migraine-specific acute treatments, ie, triptans and ergots, are usually also less effective. When patients complain that “nothing works,” either preventively or acutely, medication overuse headache should spring to mind. THE SAME HOLDS TRU WHEN TREATING PATIENTS WITH A NEUROMUSCULAR ORTHOTIC. EVEN THOUGH THE UNDERLYING PROBLEM MAY BE CORRECTED AND WILL PREVENT FUTURE HEADACHES THE PATIENT STILL SUFFERS WITHRAWAL SYMPTOMS THAT MAKE THEM FEEL THERAPY IS INEFFECTIVE. IN REALITY THE DRUG PROBLEM (IATROGENIC) ACTUALLY HIDES THE EFFECTIVENESS OF TREATMENT.

I TELL MY PATIENTS TO NOT CHANGE DRUG REGIMEN INITIALLY BUT TO CONTINUE ON THEIR CURRENT MEDS WHILE GOING THRU THE FIRST PHASE OF TREATMENT. ONCE STABILITY IS REACHED THEY CAN THEN GO THRU DRUG WITHDRAWAL THERAPY WHICH WILL BE EASIER BUT STILL UNPLEASANT.

Weaning from overused medications can restore the efficacy of previously ineffective treatments at the same time that a patient is restored to an episodic headache pattern. Thus, complete weaning is the pivotal clinical intervention. Clinically, there is no spontaneous remission from rebound without absolute detoxification, maintained for months. ONCE WEANED FROM MEDICATIONS THEY FREQUENTLY WILL NO LONGER NEED THESE MEDICATIONS ANY LONGER. IF THERE ARE STILL ISOLATED EVENTS THAT CONTINUE MEDICATION USE WILL PROBABLY BE GREATLY REDUCED.

THE FOLLOWING PARAGRAPH IS WHAT I FIND TRULY FIGHTENING ABOUT THIS PAPER. ASSUMING THE HEADACHE IS DUE TO MEDICATION OVERUSE IGNORES WHY OVERUSE OCCURED INITIALLY. THE LIST OF DIFFERENTIAL DIAGNOSIS ARE ALL POSSIBLE CUASES AND SHOULD BE INDIVIDUALLY AND COLLECTIVELY CONSIDERED BEFORE PATIENTS REACH TOXIC LEVELS OF MEDICATIONS THAT CAUSE IATROGENIC PROBLEMS. ALMOST ALL HEADACHES ARE RELATED TO TRIGEMINAL NERVOUS INPUT FROM THE JAWS AND TEETH AND IT ACCOUNTS FOR OVER 50% OF THE TOTAL INPUT TO THE BRAIN. SLEEP APNEA IS A SECONDARY CONDITION ALSO RELATING TO THE JAW POSITION.
"Other diagnoses entertained. The more diagnoses suggested for daily headache, and the more treatments tried unsuccessfully, the more likely the diagnosis is actually medication overuse headache. Because this condition is protean, patients and caregivers alike make more and more fanciful diagnoses such as allergies, cervicogenic headache, temperomandibular disorder, occipital neuralgia, chronic Lyme disease, and systemic candidiasis. A useful strategy is to assume that daily headache is likely due to medication overuse. And since medication overuse headache is generally treatable, patients labeled as having refractory headaches often are dramatically improved by appropriate intervention."

MEDICATION OVERUSE IS REAL AND A SERIOUS PROBLEM BUT TO DISCOUNT WHAT ARE POSSIBLY KEY ELEMENTS IN TREATMENT IS NOT ONLY FLWED BUT DANGEROUS BECAUSE FREQUENTLY PATIENTS WILL IN DESPERATION SEEK OUT NON-PROFESSIONALLY PRESCRIBED DRUG ALERNATIVES. NEUROMUSCULAR DENTISTRY, NUCCA, A?O CHIROPRACTIC, PHYSICAL THERAPY, MASSAGE THERAPY, TRIGGER PONT INJECTIONS AND NUMEROUS OTHER PHYSICAL MEDICINE MODALITIES SHOULD BE USED TO DECREASE PAIN AS AN ESSENTIAL PART OF MEDICATION CONTROL.

THE USE OF NON-INVASIVE INTRANASAL SPHENOPLATINE GANGLION BLOCKS CAN MAKE THE PROCESS MUCH SMOOTHER.

THE STATEMNTS "Episodic migraine attacks appear to be generated in the upper brainstem. This region in turn activates a set of peripheral pain mechanisms, ie, meningeal inflammation and vasodilation. The peripheral pain processes turn on afferent circuits that carry the pain signals to the lower brainstem, where these signals are integrated. Finally, the central signals ascend the brainstem, stimulating autonomic nuclei that account for nausea and other vasomotor changes, proceed through the thalamus, and terminate in the cortex where pain is perceived. Thus, migraine without aura consists of three steps—a central generator, a set of peripheral pain mechanisms, and a series of steps culminating in central integration. (Aura involves other steps, not outlined here.)" DESCRIBES WHAT HAPPENS TO PATIENTS BUT PLEASE NOTE THE TRIGEMINAL NERVE CONTROLS BLOOD FLOW TO THE ANTERIOR 2/3 OF THE MENINGES OF THE BRAIN. A NEUROMUSCULAR ORTHOTIC CAN HELP ADDRESS THAT INFLAMATORY/VASCULAR DILATION PROCESS. THE AFFERENTS THAT CARRY PAIN ARE PRIMARILY RELATED TO THE TRIGEMINAL NERVOUS SYSTEM WHICH IS DIRECTLY ADDRESSED BY A NEUROMUSCULAR ORTHOTIC. THE AUTONOMIC CONDITIONS ARE DISCUSSED IN THE PREVIOUSLY REFERENCED ARTICLE

I WOULD REDEFINE MIGRAINE WITHOUT AURA AS A PERIPHERAL TRIGGERS (USUALLY TRIGEMINAL NERVE BUT CAN BE OLFACTORY OR VISUAL)WHICKH THEN SETS OFF CENTRAL MECHANISM WHICH INCREASES PERIPHERAL PAIN MECHANISMS.

THE TRIGEMINAL NERVE IS THE MAJR SWITCH THAT STARTS THE PROCESS. THERE MAY ACTUALLY BE MANY PERIPHERAL SWITCHES IN ADDITION TO THE TRIGEMINAL NERVE AND WHEN THE RIGHT COMBINATION AND INTENSITY OF INPUT REACHES THRESHOLD THAN THE CENTRAL PROCESS BEGINS.

NEUROMUSCULAR DENTISTRY DEALS WITH PREVENTING INITIATING THRESHOLD FROM BEING REACHED.

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posted by Dr Shapira at 7:56 AM

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