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2017

VitD

Vit D

By: Stephanie Boville MSc., RD

As the snow and cold weather rolls in, it is often accompanied by the common cold or worse, the flu. Endurance athletes are more at risk of illness, specifically upper respiratory tract infections (URTI) because they often engage in intense training sessions outdoors that often last over an hour and athletes who are overtrained are even more at risk. Studies show that runners training for 96km/week doubled their odds of illness compared to those training only 32km/week and about 40% of marathoners experience an URTI in the 2 months of winter training leading up to a marathon race.

Along with the vigorous training, other factors such as stress, lack of sleep and inadequate nutrition can lead to immune suppression, increasing risk of illness. Being a Registered Dietitian, I would like to explain how vitamin D may help boost your immune function this winter season.

Immune function in athletes:

There are a few reasons why URTI’s are common, although this is not a complete list of all the immunological changes that occur with heavy exercise, it will provide background as to why illness is specific to the upper respiratory system.

  1. Cortisol, a stress hormone, is increased which temporarily suppress the immune system.
  2. Specific biomarkers of inflammation increase and have been linked to immune suppression.
  3. Natural Killer cell (cells that kill viruses) activity is reduced for at least 6 hours by 40-60% following exercise lasting over an hour.
  4. Nasal neutrophil phagocytosis (cells responsible for searching for and destroying bacteria) is decreased
  5. Nasal and salivary Immunoglobuin A (IgA) (antibodies secreted in the saliva which are responsible for protecting the immunity of the respiratory tract) concentration is decreased by 70% for 18h after a 31km race.
  6. Nasal mucociliary transit time is prolonged post marathon race for several days, meaning the movement of foreign particles and bacteria out of the upper respiratory tract and away from the lungs is less efficient.

All of these aspects combined demonstrate that there is possibly a window of increased risk of contracting an URTI after exercise because the immune system is compromised. The last three points demonstrate a few possible reasons to why the upper respiratory tract is so vulnerable, especially because the nose and throat are the first line of defense against pathogens entering the body.

Nutrition and Immunity:

The first point I want to make is that overall adequate nutrition plays a role in maintaining a healthy immune system. If we look at the IOC paper discussing the consequences athletes face when they are in a relative energy deficient state (inadequate overall energy intake), we see that one of the many systems affected is immunity. Therefore, you might want to think again before you try and “shred those Christmas and New Year’s gains” in mid flu season unless absolutely necessary. We need to understand that good dietary basics are necessary to support a healthy immune system before we start to get more specific with our micronutrients.

Vitamin D and Immunity:

There are three studies I want to discuss:

Study 1:

Study 1 was an observational study investigating the effects of vitamin D status on the incidence and immune function during winter training in 239 endurance athletes. They found that being vitamin D deficient resulted in significantly more symptom days and increased symptom severity of URTI when compared to optimal, adequate and inadequate vitamin D levels. They also investigated saliva samples which showed that salivary IgA concentration was significantly reduced in athletes with deficient levels of vitamin D, and that athletes with adequate, inadequate and deficient levels of vitamin D had reduced salivary IgA secretion rates compared to optimal levels. From the information in the paragraphs about we see that one area in common, the salivary IgA. Both exercise and reduced levels of vitamin D results in decreased salivary IgA concentration and secretion rates which suggests that having an optimal levels of vitamin D has an important role to play in maintaining immunity in athletes. Lastly this study found that the antimicrobial peptides in the blood were positively correlated with vitamin D status suggesting that optimal vitamin D may result in better immune function and protection.

One limitations of this study is that it was an observational study and therefore no clear links can be determined whether an intervention with vitamin D supplement in vitamin D deficient athletes will reduce frequency, length and severity of illness. Rather this study concludes that there is an association between reduced vitamin D status and increased illness length and severity along with reductions in immunological markers.

Study 2:

Study 2 investigated the effect of a 2000IU vitamin D supplement on length and severity of URTI in non-athletic adults. They supplemented participants for 12 weeks with Vitamin D or placebo and found no differences in URTI incident or severity. However, there are a few things to consider. First, we know athletes have a higher risk of URTI’s, and therefore the results may not be generalizable to an athletic population. Second, even though there was a significant increase in Vitamin D levels with supplementation it was not enough to get participants to an “optimal” level as set out by study 1 and vitamin D levels may not have been sufficient enough to show changes in immunity. Third, both groups had adequate baseline levels of vitamin D and it could be possible immune function is only compromised at inadequate or deficient levels of vitamin D. Fourth they did not do any salivary or plasma samples and therefore we can not see the immunological changes.

Study 3:

Study 3 investigated the effects of 14 weeks of 5000IU vitamin D3 supplements in 39 athletes on antimicrobial peptides and proteins. They found that the 5000IU dose for 14 weeks was enough to elevate blood levels of vitamin D to optimal levels and that 14 weeks of winter training without supplementation decreased vitamin D levels. 5000 IU of vitamin D per day resulted in significantly higher percent change in antimicrobial peptide concentration compared to placebo and increased the salivary IgA and antimicrobial peptide secretion rates. Therefore, their conclusion was that optimal vitamin D may help up-regulate the systems needed to protect against URTI.

Some limitations of this study include participants started at adequate levels of vitamin D and therefore the changes might underestimate the importance of vitamin D’s effect on immunity and bigger changes might be seen when vitamin D levels start at an inadequate/deficient level. Another limitation to this study is they did not record incidents of URTI and therefore no conclusion could be made as to whether the immunological changes resulted in decreased illness.

Main points:

Research has clearly demonstrated that vitamin D is of critical importance in the bodies immune system however there is more to learn about how vitamin D levels impact the frequency of illness and severity, and at what level is the immune system compromised.

From the studies above we learn that:

  1. Optimal levels of vitamin D increase antibacterial peptides in the blood
  2. Optimal levels increase salivary IgA secretion rates and concentration
  3. Observational studies show that illness severity and length is decreased compared to lower levels of vitamin D.

Because salivary IgA is suppressed after intense exercise and taking vitamin D increases the IgA secretion rate and concentration, this may be one mechanism that optimal vitamin D is used in to protect against upper respiratory tract infections.

Practical application:

Should we be supplementing? Usually my belief is “food first, supplement second”. With that being said, there are few foods that contain high levels of vitamin D. We can make vitamin D from the sun, however we are too far north for adequate sun exposure to make vitamin D this time of year (fall through spring). Even in the summer we may make inadequate amounts of vitamin D from the sun if we wear sunscreen, have dark skin or train inside or early/later in the evening. It is likely a good idea to supplement to make sure you are getting adequate amounts of vitamin D. Not only does it play a role in immunity, but it also helps maintain bone and muscle health, and therefore it is an important nutrient.

How much vitamin D: Health Canada has set the Adequate Intake (AI) level of vitamin D at 600 International Units (IU)/day and the upper limit at 4000 IU/day for most ages with some exceptions. First AI means that there is not sufficient evidence to set a Recommended Dietary Allowance (set to meet the needs of 97-98% of healthy individuals) but the AI is assumed to be adequate. There is debate about the AI for vitamin D as many think this AI is set too low, and people are also supplementing over the upper limit (like in study 3 from above). In the following years this AI could see and increase.

Food Sources: People often think milk is the best source of vitamin D, however 1 cup of milk only provides around 100IU or 1/6 of your daily needs of vitamin D. One of the best sources is actually salmon, which, depending on the kind can provide anywhere between 200-600IU in one 2.5oz serving (the size of a deck of cards).

Supplements: Depending on diet and your current vitamin D status, supplementing with 1000-2000IU is should be enough to give your vitamin D levels a boost and is recommended, especially in the winter.

There are many other tactics athletes can try to maintain and help with increased immune function. If you would like to learn more, book an appointment so we can optimize your nutrition intake to support your health, wellbeing and athletic performance!

Related Article: Does Vitamin C help to prevent the common cold?  Check out Dr. Delanghe’s past article.

Reference:

Nieman, D.C. Exercise effects on systemic immunity. Immunology and Cell Biology. 2000. 78: 496-501.

Gleeson, M. Immunological aspects of sport nutrition. Immunology and Cell Biology. 2016. 94: 117-123.

He, C.S., Handzlik, M., Fraser, W.D., Muhamad, A., Preston, H., Richardson, A., Gleeson, M. Influence of vitamin D status on respiratory infection incidence and immune function during 4 months of winter training in endurance sport athletes. Exerc Immunol Rev. 2013. 19: 86–101.

Li-Ng M., Aloia, J.F., Pollack, S., Cunha B.A., Mikhail, M., Yeh, J., & Berbari N. A randomized controlled trial of Vitamin D3 Supplementation for the prevention of symptomatic upper respiratory tract infections. Epidemiol. Infect. 2009. 137: 1396-1404.

He, C.S., Fraser, W.D., Tang, J., Brown, K., Renwich, S., Rudland-Thomas, J., Teah, J., Tanqueray E., & Gleeson. M. The effects of 14 weeks of vitamin D3 supplementation on antimicrobial peptides and proteins in athletes. Journal of Sports Sciences. 2016. 34: 67-74.

Version 3

We are extremely excited to welcome the newest member of the Delanghe Chiropractic and Health team: Stephanie Boville MSc, RD.

From weight loss and managing osteoarthritis, all the way to sports nutrition, Stephanie will be here to help you conquer any and all of your dietary concerns and goals!  With 6 years of post secondary education, and a strong science/evidence- based approach, only advice based on the BEST available research will be implemented.

No cleanses, magic powders or fad diets and no guessing.

How many grams of carbohydrates will you need to optimize your marathon performance?  Are you getting in enough protein to maintain muscle and enhance performance?  Are you taking in the right foods to decrease the pain and inflammation associated with arthritis?  Stephanie can help you!

What it takes to be an RD:

The process of becoming a registered dietitian is unlike any other designation for those offering advice on diet.  RDs are highly educated and trusted professionals for a reason!

The first step in becoming a dietitian is to complete a 4 year undergraduate degree from an accredited university program.  Once the future dietitian has completed their undergraduate degree, they must apply to an accredited internship program or masters program, which can be very competitive and must be accepted within 3 years of graduating from their undergraduate degree. The internship or masters program require the future dietitian to complete various competencies and log hours working under a certified dietitians. Rotations include public or community health settings, food service, diabetes, inpatient units and outpatient units within the hospital. If that isn’t enough, the dietitian is then required to write a 6 hour regulatory exam to demonstrate their knowledge and competence of being employed as a dietitian before they receive certification. Once the dietitian receives their certification, they are required to submit yearly self directed learning tools to prove to the college that they are committed to continuing their education and improving their skills in their nutrition practice. They are also subjected to randomly being selected for peer and practice assessment where the dietitian is evaluated by both patients and co-workers to assess their work performance and competency. If anything unusual is revealed in these assessments there could be further investigation by the college into the dietitian and action if they are found to be incompetent.  Because of this long road to become a RD, it’s clear why they can be the professionals trusted with your dietary health!

To learn more about Stephanie and her hours, click HERE.

Too book an appointment, call (519)885-4930.

acu

What is Acupuncture?

Modern acupuncture is defined as a therapeutic technique in which sharp, thin needles are inserted into specific points on the body. Mechanical, electrical or physical stimulation is sometimes added to the needle to increase the effect. Needles are inserted into acupuncture points, aka: acupoints which were first established in traditional Chinese medicine.

Classical vs. Anatomical Acupuncture: What’s the difference?

Classical acupuncture is based on Tradition Chinese Medicine (TCM). Ancient Chinese believed that everything in the universe was energy. The philosophy that emerged from this thinking is called Taoism which translates to the energy of the universe. The energy is also referred to as Qi (chi).

Qi consists of two equal and opposing energies, Yin and Yang and is commonly represented by the picture above. The curved line represents movement and dynamic fluid between the 2 energies. They are mutually supportive and interdependent.

It was believed that Qi flows through the body along energy channels (referred to as meridians) and could flow into specific sites aka: acupoints. If Qi was deficient, blocked, or out of balance, symptoms such as pain would appear. Needling these sites relieved the symptoms by unblocking and restoring flow of Qi and re-establishing energy balance in the body.

Anatomical acupuncture was originated by Dr. Joseph Wong in the mid 1970s and bridges the gap between TCM and Western medicine. The acupoints are chosen based on anatomy and physiology.

The main difference between classical and anatomical acupuncture is the paradigm used in the selection of points.

The Points

Early studies show most acupoints are located on or near peripheral nerves. There is no evidence to support the existence of new or special structures under these acupoints, however, histological studies (ie: looking under a microscope) have shown a higher concentration of neural tissue and neuroactive components at acupoints compared to non-acupoints.

Neural tissues are the actual tissues themselves and include nerve endings and sensory receptors. Neuraoactive components are cells that release chemical mediators that can excite or inhibit signals to the brain.

The Neural Acupuncture Unit (NAU)

The NAU is a collection of the neural and neuroactive components surrounding the needle. In the diagram, the NAU is the area within the dotted lines. These tissues would be stimulated by the needle.

What Happens When the Needle is Inserted?

Local Effects

When a needle is inserted, it causes some damage to the issue near the insertion point, which stimulates a chain of biochemical reactions in your body. As a result, your body produces various inflammatory and immune response in the NAU. Basically, it is a micro-injury which does negligible harm to the body while creating a therapeutic response.acu2

Non-local Effects

Without getting too in-depth, the non-local effects involve altering pain signals through receptors in the spinal cord and how they relay messages to the brain. The nerve signals from the local tissue travel to the spinal cord and through complex mechanisms, block the original pain signals from getting to the brain.

Another area of the brain is also involved. The hypothalamus-pituitary complex (don’t have to remember this name!) is also stimulated when a needle is inserted and releases anti-inflammatory chemicals into the bloodstream that can help to reduce pain.

These local and systemic responses help to explain the pain-relieving effects of acupuncture.

In my next article, we’ll look at the effects that acupuncture can have for different injuries!

REFERENCES:

Wang, Kain, White. Acupuncture analgesia: I. The scientific basis. Pain Medicine. 2008

Zhang, Wang, McAlonan. Neural acupuncture unit: A new concept for interpreting effects and mechanisms of acupuncture. Evidence-Based Complementary and Alternative Medicine. 2012

training and performance

Welcome back to another protein-focused edition of Training & Performance! My last article looked at the evidence in support of avoiding protein while you run. Today, I will discuss one of the more common questions I hear at my practice: does protein timing and distribution matter? And should you be consuming protein directly after a workout?

iron sources

Muscle/Protein Physiology

Our muscles are in a constant state of breakdown and renewal. For the average person (depending on factors such as age and level of activity), muscles are broken down and rebuilt at a rate of 1-2%/ day. To help support this renewal, the building blocks of muscle (amino acids) need to be taken in on a regular basis.

While the amino acids we ingest provide the raw material to support that 1-2% renewal rate, that is not all they do. The act of ingesting amino acids also triggers a physiological cascade that signals more muscle growth. So, when the body is being fed amino acids, not only does it have the material for muscle growth, but an anabolic muscle-building state is also put into action!

So it’s no surprise that ingesting protein is important to muscle growth. Now the question is, how much and how frequently do we need to ingest protein to optimize both of these benefits and maximize our gains?

Click HERE to read the rest in the Run Waterloo Magazine.

training and performance

I have written many times(1234)  about the importance of ingesting carbohydrates during a race (if it’s long enough).

I’ve also discussed how taking in other sources of fuel, like protein, is not the best move due to it triggering an increased risk of GI distress. The reason: in part, protein is not absorbed and metabolized as quickly as carbohydrates. Delayed gastric emptying results in water diffusing into your guts and increasing the odds of needing to take a PB-killing washroom break! iron sources

One thing I have heard in response to this tip from patients and athletes at H+P is that IF one is able to handle protein from a GI standpoint, is it worth experimenting with on top of carbohydrates as a fuel source? Is there an additional benefit to taking in protein during a race if it doesn’t bother your stomach? That is what we’ll be looking at with this article.

CLICK HERE to read the rest in the RunWaterloo magazine!

TFL

What is it?!

Overuse injury associated with pain on the outside (lateral) part of the knee

Anatomy

The ITB is a band or sheath of fibrous connective tissue that surrounds the muscles on the outside of the thigh and crosses both the hip and knee joint. It originates from the tensor fascia latae (TFL) and gluteus maximus muscles and then continues down the femur (thigh bone) where it attaches to both the femur and tibia (shin bone) on several bony landmarks.

The function of the IT band is to stabilize the hip and knee as well as limit hip adduction (leg moving towards the midline) and internal rotation of the knee.

Epidemiology and Risk Factors

The knee is the most commonly injured area in runners – accounting for 25-42% of all running injuries. ITBs is the second most common knee injury for runners with patellofemoral pain syndrome being first.

ITBSigns/Symptoms

Runners usually have no exact history of trauma and find that the pain comes on gradually over the outside of the knee during a run. The pain usually appears within a few km of a run and increases in intensity. That same area can also be tender to touch.

Pathophysiology/Etiology

There are a couple theories on the pathophysiology of ITBs.

Some researchers believe that ITB inflammation is a result of excessive friction between the ITB and the boney prominences which occur when the ITB slides over the boney structure and causing inflammation during repetitive movements such as running. Others have argued that rather than the ITB band causing excessive friction, the inflammation is caused by the ITB compressing an area of highly innervated fatty tissue between the IT band and boney prominence

Contributing Factors to Developing ITB Syndrome

The most common factor in developing ITBs is an increase in exercise intensity through mileage, hill training or speed work.

Other reported possible causes which may increase tension in the ITB by altering hip and knee angles include:

  • Downhill running
  • Wearing old shoes
  • Always running on same side of road
  • Leg length discrepancies
  • Excessive pronation of the foot (foot rolling inward)
  • Tight ITB
  • Weakness of glute medius muscle

ITBs and Running Biomechanics

It has been suggested that injuries can manifest as a result of an increase in exercise intensity beyond a threshold level, combined with certain intrinsic factors in athletes.

A recent systematic review looked at biomechanical variables and investigated whether distance runners who suffer from or develop ITBs have different biomechanics than runners who do not develop ITBs.

The evidence shows that it is unlikely that abnormal biomechanics at the foot or shin bone can contribute to increasing tension of the ITB.

The results suggest more is happening at the hip and knee. Runners who eventually develop ITBs have more internal rotation at the knee and greater glut medhip adduction angles during the stance phase of running (when the foot is in contact with the ground) compared to healthy controls.

Some researchers have found that this internal rotation of the knee is due more to an externally rotated femur (thigh bone rotated outside) and suggests this may be due to insufficient activity in the medial rotators of the hip (gluteus medius, gluteus minimus, TFL).

As for muscle strength and endurance, there is currently no evidence to suggest that reduced muscle strength plays a role in ITBs. However, the research is limited because many of the trials give inaccurate impressions of a muscle’s functional strength. Future research is needed to look at the timing of muscle action rather than the magnitude of strength.

Research also suggests that runners with current ITBs tend to have more trunk flexion than healthy controls. It is uncertain whether the increased trunk flexion is due to a tight ITB or if the ITB becomes tight as a consequence of the flexed trunk (aka: the torso leaning forward)

How do we treat it!?

Stay tuned to my next article on the latest evidence for treating and managing ITBs!

References:

Foch et la. Associations b/n IT band injury status and running biomechanics in women. Gait & Posture. 2014.

Louw & Deary. The biomechanical variables involved in the aetiology of iliotibial band syndrome in distance runners – a SR. Physical Therapy in Sport. 2014

iron sources

When it comes to performance, there’s no doubt that nutrition plays a significant role. In the past, I’ve really focused on acute nutrition: what you can do directly before or during your run to be faster (i.e. here).

training and performance

An area I have neglected to focus on is what you should be doing from a nutritional standpoint on an on-going basis to stay healthy and perform at your best. One key area that I see as a recurring problem in my practice and athletes around me is iron deficiency anemia.

Iron has a number of roles in the human body. The most important function is how it is incorporated into hemoglobin and myglobin to facilitate oxygen transportation. If these proteins decline, our ability to transport oxygen to our working muscles also drops, and performance plummets along with it (such as here and here).

CLICK HERE to read more in the RW Magazine

training and performance

Well, it’s safe to say that the hot summer days of running are here! With many big races on the horizon, including the Waterloo Classic, it’s important make sure we do our best to prepare for the additional challenge heat provides.

gregIt’s a topic I wrote about briefly in the past, but this week I wanted to take a closer look at things. Two strategies I discussed before were (1) getting acclimated to the heat and (2) pre-cooling.

Both of these strategies make sense logically.  If you practice running in the heat, your body will be better equipped to handle it. In the case of pre-cooling, if you start with a cooler body temperature, then there is more wiggle room before your body really has to make the push to cool off. But what does the research show, and how well does each strategy work?

Click HERE to read the rest in the RW Magazine.

I’ve written a few times (1, 2, 3, 4) before about how important it is to ingest carbs while racing a distance that takes over ~40-60mins to enhance performance. There still seems to be some resistance to doing this; some of it is fueled by pseudoscience, but some is fueled by the very legitimate concern that ingesting 30-60g of glucose/hour will cause GI distress and potentially an even more detrimental impact on performance.

There’s no doubt, GI distress is often caused by factors other than the carbs ingested during the race (such as ingesting slowly absorbed, slowly metabolized fat, protein or fibre in close proximity to or during a race). So before trying to fix your carb situation, first make sure that it is indeed your problem.shutterstock_335916845

Training the Gut

So how do we train the gut?  And does it work?  CLICK HERE to read my latest in the Run Waterloo Magazine. 

glut med

Let’s target the hip abductor muscles! In my last article I discussed the importance of core strength and control to stabilize our trunk when we run – specifically the importance of the hip abductor muscles.

To refresh, the hip abductors help to bring the leg to the outside of our midline to counteract the moment of force where our leg naturally wants to move toward the midline each time our foot hits the ground.

We have several hip abductor muscles in our body, the majority of them are in our butt muscles! Gluteus medius (Gmglut meded), gluteus maximus (GMax), gluteus minimus (GMin) and TFL (tensor fascia latae). The focus of this article is going to be on the gluteus medius because of its important role in stabilizing the pelvis.

Why do the gluteal muscles become weak? Most of us spend our days sitting and therefore develop weak gluteal muscles making it harder to recruit them during exercise. This can lead to improper use and poor muscle patterning of other muscles to try to compensate for a weak GMed which may increase risk of injury somewhere down the road.

Using techniques to help isolate these muscles can increase their activation and ultimately improve performance. So, how do we target these muscles? A few electromyographic (EMG) studies can help us out!

Study #1: One leg vs. two legs for Gmed activation 

This study used EMG signal amplitude to measure GMed activation in 5 different weight-bearing exercises; double leg stance, single leg (SL) stance, single leg squat, single leg stance on a cushion, and single leg squat on a cushion, where the cushion was an unstable surface underneath the foot to make the exercise more difficult.

To no surprise, the results showed that a SL stance placed higher demands on the GMed than double leg stance and SL squats are more demanding than SL stance. As for the SL exercises on the cushion; the GMed muscle was activated more, but not significantly more than on flat ground.

Study #2: How do we activate Gmed even more?

This study used EMG signals to measure muscle activation patterns of the GMed (among 3 other hip muscles) during 5 unilateral weight-bearing exercises as shown here:
picss

They compared the level of activation to the subject’s maximal voluntary contraction. The EMG signal amplitude had to be between 40-60% of the maximal voluntary contraction to have sufficient intensity for strengthening.

Of the 5 exercises, the results for the GMed showed the highest amount of activation during the wall squat! The next exercises for activation were as follows: forward step-up, lateral step-up, backward step-up and then mini squat. The authors suggested that these exercises may be used as progression exercises towards the wall squat.

TFLStudy #3: What happens when the gluts are weak?

The last article looked at hip abductor muscle activity during resisted side-stepping exercises in either a squatted or standing position. They found that both the GMax and GMed had greater muscle activity during the squatted position than the upright posture. By being in this squatted position, the TFL muscle is less active which means the gluteal muscles should, in theory, be more active. This is important because if the gluteal muscles are weak, the
TFL will compensate which may lead to further underuse and weakening of the gluteal muscles.

Practical Applications

Here are a few key take home points for activating the Gmed to help enhance our running:

  • The GMed plays an important role in stabilizing the pelvis/hip joint during weight-bearing
  • GMed activation is greater when the base of support is less ie: during a side bridge, unilateral squat and lateral step up
  • Some key exercises to get the most activation from the GMed:
    • Single Leg Stance
    • Single Leg Wall Squats
    • Forward Step Ups
    • Lateral Step Ups
    • Side Steps with a resistance band around the knees/ankle (aka: Monster Walks)

And does strengthening GMed actually help to prevent injuries?  As always, the answer is that it depends, but check out this article  from Dr. Delanghe exploring how GMed strength work can decrease injury-causing variability of motion at the knee.

Happy strengthening!

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