ORIGINAL ARTICLE. A clinical and Investigative study of hair loss in adult female

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1 ORIGINAL ARTICLE A clinical and Investigative study of hair loss in adult female Krina B. Patel 1*, Avni V. Gandhi 2, Ruchin B. Patel 3, Venu R. Shah 4, Sudhir B. Pujara 5 1 Associate Professor, GMERS Medical College & Hospital, Sola 2 Consultant Dermatolgist, Surat 3 Medical Graduate, BJ Medical College, Ahmedabad 4 Assistant Professor, P & SM Department, GCS Medical College, Ahmedabad 5 Professor & Head (Retired) Smt. SCL Hospital, Ahmedabad ABSTRACT BACKGROUND: Hair is a typical mammalian skin appendage which has more of cosmetic significance at present. Alopecia meaning absence or loss of hair in female can be associated with poor quality of life in affected patients. Material and methods: This study was done in 100 female patients of age above 18 years presenting with complain of diffuse hair loss. Detail history and complains of all patients were recorded. General examination, local examination and investigations including semi-investigative tests were done to classify the patient in different hair loss types. Observation: Out of 100 patients of hair loss, most common age group affected was 30-40years (42%), 58% patients presented with complains of diffuse hair loss and more than 50% presented within 6 months of onset of symptoms. Telogen effluvium either acute or chronic was most common diagnosis (53%) followed by chronic diffuse hair loss and Female pattern hair loss. Specific etiological factors were found in 52% of patients. Trichogram abnormalities were found in 60% patients. As opposed to common belief, anemia was not found to be statistically significant in patients with hair loss. Conclusion: Detailed history, clinical examination and investigations reveal multiple types of hair loss which can have many systemic associations also. Successful treatment of hair loss condition requires perfect diagnosis of type and etiological factor associated with hair loss in female. Key Words: Diffuse hair loss, alopecia, adult female. INTRODUCTION Hair is a cutaneous appendage typical to mammalian skin. In the present day, hair has lost much of its biological significance but its cosmetic and psychological value is much enhanced. Hair loss is a common complain for which patients of both sexes and any age present to the skin specialist. Alopecia defined as absence or loss of hair 1 is a benign condition but it causes substantial psychological damage. It reduces the quality of life of patient and leads to profound emotional suffering, personal, social and work related problems. 2 Female patients presenting for hair loss are grave sufferers. Inevitability of baldness in men; genetically predisposed to male pattern hair loss is to an extent acceptable to man while loss of hair from scalp in women is no less distressing *Corresponding Author Dr. Krina B Patel, Associate Professor, GMERS Medical College, Sola, Ahmadabad, than growth of body or facial hair in excess of the culturally acceptable norm; even subtle loss in women may be much greater problem than overt loss in man. 3 The impact of hair loss in women is so high that about 40% women report marital problems, 63% women claim to have career related problems. They also suffer lower self esteem, poorer quality of life and poorer body image. 2 Anything that interrupts the normal cycle of hair growth can trigger diffuse hair loss. Triggers include wide variety of psychological or emotional stress, nutritional deficiencies, endocrine imbalances and others. In addition, hair loss may be a manifestation of more general medical problem. It can be a manifestation of systemic disease and its study leads to insight into many systemic disorders. 3 The first step in effective management of hair loss is to identify the cause, which may be complicated by one or more secondary factors; the second is to find effective treatment options and the third is to establish plans for long term management Int J Res Med. 2014; 3(4);28-36 e ISSN: p ISSN:

2 Methods: This study was done on 100 Investigations included complete hemogram, female patients presenting in skin OPD of a Serum VDRL test and Serum HIV antibody teaching institute between September 2007 test in all patients and serum ferritin level, to August All female patients above thyroid function tests, hormone levels 18 years of age who presented for chief (Dihydroepiandrostenidione (DHEAs), complain of scalp hair loss were included in Serum Follicle stimulating hormone(fsh), the study. Patient data were recorded on a Serum Luteinizing hormone( LH), Total standard proforma. plasma testosterone) as and when required. The demographic data included age, marital KOH examination of scrapings of scalp and status, religion, diet and occupation. Other scalp biopsy were done when indicated and relevant data recorded were height, weight required. Other relevant investigations done and habits. in indicated patients were ANA titer, renal Complains of the patients recorded were and liver function tests and USG diffuse hair loss, visible thinning, patchy examination of abdomen and pelvis. hair loss or decrease in hair density or Specific non-invasive and semi-invasive combination of any of these. Important investigations included daily hair count, hair history points recorded were duration of hair pull test and trichogram. loss, origin and progress of hair loss, Daily hair count is a quantitative assessment episodic or continuous hair shedding, of actual hair loss. The patient is asked to identification of triggering factors and their collect all possible hair lost throughout the temporal relationship to hair loss, associated day including those on shoulder, pillow etc.; symptoms like scalp itching, seborrhea, then all hair are counted and recorded. This headache were recorded. History also is done for consecutive 7 days. Normal hair included acute or chronic blood loss, atopy, lost per day is average If total hair stress, thyroid disorder if already diagnosed, lost in a day is more than 100 it is crash diets, anorexia nervosa or bullemia. considered significant and lost hair can be History of recent illness, surgical examined for any pathology in bulb or shaft intervention, blood loss, hospitalization or anomaly. 5,6 chronic illness was noted. Any medicines Hair pull test is a test where approximately taken in recent past, history of diabetes 60 hairs are pulled with a constant traction. mellitus, hypertension, malabsorption, renal Bulbs are examined for number of telogen disease, any other systemic illness were hair. If telogen hair present are more than noted. History related to recent childbirth 10% it is considered positive sign for hair and abortions were noted. History of use of loss. Patients are advised not to wash hair hair cosmetics, hair products or hair one day before coming for test. If anagen procedures was recorded. History of mood hair are pulled during pull test, it is a sign of disorder, hair pulling habit etc. was also cicatricial or other causes of anagen hair loss noted. Any past history of similar complains and is always pathological. 5,6 in patient or family members were recorded. Trichogram is done to study the hair cycle Menstrual and obstetric history of patient more accurately hairs from different was noted. parts of the scalp are taken for evaluation. All patients general examination was Patients are asked to wash hair three to five carried out to look for any abnormality days before coming to clinic hair are present. Local examination of scalp included selected from different parts of scalp. Then type of hair loss whether diffuse or holding in artery forceps with rubber tubing; localized, scarring or non-scarring or hair are pulled in direction of natural hair patterned, color of hair lost, presence of growth. Hair pulled are cut 1 cm away from scaling, crusting, pustules, seborrhea, any bulb and are arranged on slide and examined other infection or infestation of pediculosis. under microscope to determine percentage Loss of eyebrows, eyelashes, loss of hair of hairs in anagen, catagen and telogen. from any other body site, nail changes, signs Ratio of anagen to telogen (A/T ratio) is of virilization etc. if present were noted. calculated. Upto 10% telogen hair frequency 29 Int J Res Med. 2014; 3(4);28-36 e ISSN: p ISSN:

3 on trichogram is considered normal, upto 25% is found in diffuse hair loss and more than 35% telogen hair is considered severe problem. 6 Depending upon the history, clinical findings and results of semi-invasive investigations; patients were diagnosed as having acute telogen effluvium(ate), chronic telogen effluvium(cte), chronic diffuse telogen hair loss(cdthl), female pattern hair loss(fphl), alopecia areata(aa), cicatricial alopecia(ca), traumatic alopecia(ta), local infection induced alopecia, anagen effluvium(ae) and others. Diagnostic features considered for each type of hair loss were as follows ATE history of recent acute illness or pregnancy or any other triggering event within past 6 months with acute onset of hair loss. No scalp abnormality, no associated findings, Hair pull test strongly positive, trichogram showing reverse anagen to telogen ratio ( 1:6 or more)/ telogen hair more than 15% CTE hair loss for more than 6 months, history suggestive of ATE which continued to chronic hair loss, no scalp abnormality, hair looks normal but bitemporal recession may be noted, hair pull test positive from vertex and occiput. Trichogram showing chiefly telogen hair. CDTHL history of persistent hair loss for more than 3 months; on investigation iron deficiency or thyroid dysfunctions or zinc deficiency or other causes like drug history, crash dieting, malabsorption disease, liver or chronic renal dysfunction, other chronic illnesses including HIV infection may be found. Hair pull test may or may not be positive. Trichogram shows decreased anagen to telogen ratio. (8:1, normal 14:1) Terminal to vellus hair ratio (Normal 8:1) is preserved on scalp biopsy with decreased anagen to telogen ratio. AE- history of drug which may cause AE like cytotoxic medicines, allopurinol, colchicine etc. Trichogram showing chiefly anagen hair. FPHL positive family history, middle aged female, gradual imperceptible hair loss with obvious thinning, widening of parting or frontot-temporal recession. Hormonal abnormality on hematological investigations and USG abdomen showing signs of PCOS associated with other signs of hyperandrogenism like hirsutism may be present. AA sudden hair loss which is generally patchy, on examination exclamation mark hair present, no scalp abnormality detected. Trichogram from advancing age showing exclamation mark hair, biopsy showing typical perifollicular inflammation. Other signs like nail pitting, history of atopy, history of other autoimmune disease like vitiligo, peptic ulcer, diabetes mellitus Trichotillomania patchy and uneven hair loss from reachable sites, no scalp abnormality except occasionally signs of scratching, obvious mental disorder like obsessive compulsive disorder. Scalp biopsy showing pigment cast. Cicatricial alopecia history of itching or tenderness on scalp with patchy hair loss, scalp showing changes of inflammation and atrophy or scarring. History of or signs of lichen planus or discoid lupus erythematosus or other inflammatory disorder. Infection associated hair loss signs and symptoms of bacterial or fungal infection. KOH examination of scalp scrapping showing hyphae and spores in tinea capitis. Statistical analysis was done on Epi info version 7 and word excel. The Chi-square test with Yates correction ws used to find the significance of difference in more than two proportions. Test was used where ever applicable according to the sample size and type of data. RESULTS Table: 1 Age distribution Age in years Number of patients years 33 (33%) years 42 (42%) years 20 (20%) years 3 (3%) Above 60 years 2(2%) This study was done on 100 patients above 18 years of age presenting to skin OPD with complain of scalp hair loss. 78% women were married and 16% were unmarried; 30 Int J Res Med. 2014; 3(4);28-36 e ISSN: p ISSN:

4 while 6% women were widowed or divorcee. Most common age group presenting for complain of hair loss was years (42%). (Table 1) Most of the patients 78% were Hindu while 22% % were Muslim and other religion patients. 68% women were vegetarian; while rests were consuming mixed foods. 61% were housewives, 20% were students and 19% were working women. Table: 2 incidences of different clinical presentations of hair loss Pattern of hair loss at presentation Number of patients(%) Diffuse hair loss (dhl) 46 Visible thinning (vt) 21 Dht + vt 8 Dhl + decreased hair density (dhd) 10 Patchy hair loss with/without dhl 15 Table:3 Incidence of duration of hair loss Duration of hair loss Number of patients (%) < 1 month 16 1 month 6month 36 6months 1year years years 15 >5years 2 Table: 4 Incidence of average hair loss per day Average number of Number of patients hair lost per day (%) >250 4 <70 or not applicable 23 Table 1to 4 showing age wise distribution, presenting complains, duration of hair loss and average number of hair loss respectively in study population Table: 5 Incidence of disease Diagnosis Number of patients (%) Ate 31 Cte 22 Cdhl 16 Fphl 10 Aa 6 Ca 3 Traumatic alopecia 4 Local infection 4 induced Others 4 Table: 6 Age distribution of specific disorders No. Of pt years years years years >60 years Total Ate Cte Cdhl Fphl Aa Ca Ta Li Other Total Chi square value 75.7, p value< (difference is significant) Table: 7 Comparison between duration of hair loss and type of disease Disease/ number < 1 month 1-6 month 6month 1year 1-2 years 2-5 years > 5 years Ate n= Cte n= Cdhl n= Fphln= Aan= Ca n= Ta n= Local infection n= Others n= Total n= Chi square value 132.7, p value < (difference is significant) 31 Int J Res Med. 2014; 3(4);28-36 e ISSN: p ISSN:

5 ATE CTE CDHL FPHL AA CA LOCAL INFECTION TRAUMATIC OTHERS Table 5,6 and 7 showing incidence of hair disorders, comparison with age and duration of hair loss with type of hair disorder. Table: 8 Etiological factors of hair loss Causes Number of patients(%) Febrile illness 7 Stress 5 Telogen gravidarum 4 Infections 4 Severe anemia 9 Thyroid dysfunction 6 Chronic illness 4 Drug induced 5 Trauma 4 Scarring disorders 4 Idiopathic 48 Table: 9 Trichogrm result Trichogram findings Number of patients T 10%-15% 12 T > 15-20% 15 T > 20-25% 5 T > 25% 2 T + d 8 Hair shaft anomaly 2 Predominant anagen 2 Normal 54 T = telogen, d = dystrophic Table: 10 Incidence of anemia with specific disorders Diagnosis Severe anemia hb<8gm % Moderate anemia Hb8-10 gm % Mild anemia Hb10-12gm% Normal hemoglobin level Ate Cte Cdhl Fphl Aa Ca O Ta O Li O Others O Total Chi square value 17.0, p value 0.8 ( difference is not significant) Table 8,9, and 10 showing etiological factors, results of trichogram and incidence of anemia in study population respectively. Chart: 1 showing incidence of disease specific clinical presentation 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Figure: 1 different patterns of presentation. a diffuse hair loss, b visible thinning, c visible thinning + patchy hair loss, d FPHL widening of parting, e alopecia with scarring1.5 A c DHL+PATHCY DHL+DHD DHL+VT Figure: 2 Diffenent types of hair loss a,,a ATE, b CTE, c,c CDHL, d AA, a B a VT DHL D E 32 Int J Res Med. 2014; 3(4);28-36 e ISSN: p ISSN:

6 b b a b c d Figure: 6 Traumatic hair loss due to a hair straightening procedure, b traction alopecia a b Figure: 3 CA due to a LE associated CA with skin lesions of SCLE on chest, b Brunsting Perry pemphiogid, c pseudopelade of Brocq a a Figure: 7 biopsy findings in a alopecia areata showing perifollicular lymphocytic infiltrate (H& E 40X), Brunsting Perry pemphigoid showing subepidermal blister with eosinophilic infiltrate (H&E 10X) a b b c Figure: 4 anagen effluvium due to cancer chemotherapy Figure: 5 hair shaft deformity on trichogram a trichorrhexis nodosa, b trichoclasis We found maximum number of patients presenting with complain of diffuse hair loss (58%). Other presentations were found in variable number of patients (Table 2). (Figure 1 a,b,c,d,e ) More than 50% patients presented within 6 months of onset of symptoms. (Table 3) Average hair loss per day was in 38% patients (Table 4) Most patients were diagnosed as having telogen effluvium either acute or chronic (53%) followed by CDHL (16%) and FPHL (10%). (Figure 2 a,b,c,d) Other types of hair loss were found in 3% -6% patients. (Table 5) Correlating the type of hair loss with clinical presentation of patients (Chart 1) it was found that 100% patients of ATE presented with complain of diffuse hair loss while in other disorders various 33 Int J Res Med. 2014; 3(4);28-36 e ISSN: p ISSN:

7 combinations of presentations were found. patients while mild anemia was found in Correlating type of hair loss with duration it 68% patients, rest having normal was found that all patients of ATE presented hemoglobin level. As serum ferritin level within 6 months while most patients of estimation could not be carried out in all FPHL presented after 1 year of starting of patients due to unavailability in hospital, 27 hair fall (Table 6) patients with mild anemia got it done and in In comparison to age and specific hair 3 patients it was found to be decreased. disorder; 47% patients of ATE were of 20- Results of incidence of anemia with specific 30 years of age group. CTE was found in 20 disease is shown in Table 10. Out of years age group. 63% patients of FPHL patients of age group years; were between years of age. 80% of subjected to hormonal assay and pelvic traumatic hair losses were between sonography; significant hormonal years age group. (Table 7) Specific abnormalities were found in 7 patients etiological factor was found in 52% patients (16.66%) with increase in DHEAs, reverse while in 48% no definite cause could be FH:LSH ratio and increase/ normal found. (Table 8) In patients with ATE 16 testosterone level and PCO disease was patients (51.6%) had precedent febrile detected in 3 patients (7.1%) on sonography. illness, while mental stress, anemia, Serum VDRL was found reactive in one childbirth were other causes found in 11 patient with CDHL (titre >1:16) and HIV patients (35.4%) patients while in rest 16% infection was detected in one patient with patients no cause could be identified. In CD4 count >500 at the time of detection. patients with CTE thyroid dysfunction was Biopsy was done in one patient with diffuse found in 9 (41%) patients, while chronic and patchy hair loss in which AA was illness, anemia and drug induced were found confirmed, in patients of CA, diagnosis were in 31.8% patients, in 27.2% patients no confirmed in all three cases on cause could be identified. Isotretinoin was histopathology and in case of the culprit drug in both patients of drug trichotillomania were also classical findings induced CTE. Discoid Lupus were found. (Figure 7 a, b, c) erythematosus, pseudopelade of Brocq and CONCLUSION Burnstring Perry Pemphigoid(variant of Diffuse hair loss is frequently encountered Bullous pemphigoid) (figure3 a,b) were condition for which adult female patients etiological factors in patients with cicatricial present to dermatology OPD. Hair loss can alopecia. Chemotherapy was responsible for have many etiological factors obvious or anagen effluvium in 2 patients (figure 4) and hidden. Presenting complain of patient may hair shaft anomaly found in 2 patients were also vary and diagnosis of hair loss depends trichorrhexis nodosa and trichoclasis (Figure upon consideration of multiple factors in a 5 a,b). Local infections like tinea capitis patient aided by required hair specific wers found in 4 patients, associated investigations. seborrhoeic dermatitis was present in 23% In present study, most common age group patients but that could not be directly presenting with complain of hair loss was 30 correlated to hair loss. Traction alopecia, 40 years and most of the patients (55%) trichotillomania and permanent hair fall under year group. In studies by straightening were found to be causative Santamaria et al [7] and Lee et al [8] most factors in patients with traumatic frequent age group reported were between alopecia.(figure 6 a,b) years and 3 rd to 4 th decade Results of trichogram is shown in Table 9 respectively. Diffuse hair loss was the most which shows that in 40% of patients no common presenting complain (46%) in our trichogram abnormality was found. patients. This highlights the fact that overt Moderate to severe anemia was found in 19 baldness is generally rare in female patients 34 Int J Res Med. 2014; 3(4);28-36 e ISSN: p ISSN:

8 though they always fear of the same. Most of the patients in our study (74%) presented within 1 year of starting of hair fall which coincides with the finding of appreciable thinning in patients with diffuse hair fall. Only patients presenting within 1 month of starting of symptoms were in ATE or AA and local infection induced hair loss. Average hair loss was above 100 in most of the patients in our study but it is also worthwhile to note that 23% women do not had significant hair loss as per daily hair count still they were concern with diffuse hair loss which again emphasize the importance of hair for psychological wellbeing. Most of the patients of ATE, CTE and CDHL were below 40 years of age while most of the patients of FPHL were above 30 years of age. All patients of AA were also falling in younger age group. While patients with CA, TA and LI induced hair loss presented at any age. In various studies telogen effluvium is reported to be 28% - 92% 9,10,11 and FPHL is reported to be between 7% to 60% 9,10,12 depending upon the age group studied. In present study also we found most of the patients (53%) with TE either acute or chronic and patterned hair loss in 10% of our patients. Only 1 of our patient with patterned hair loss had significant temporal and vertex balding while in all other patients bitemporal or frontal balding associated with diffuse thinning was found. 1 patient with AA rapidly turned into alopecia totalis within 3 months while others had only patchy hair loss. Febrile illness as precipitating factor for TE is found in 2% - 33% 9,13,14 in various studies and telogen gravidarum is found in 9.33 to 21% patients in various studies 7,9,13,14. In our study febrile illness was etiological factor of hair loss in 7% patients while telogen gravidarum was found in 4% patients. Lower incidence of Telogen gravidarum reporting in our study could be due to cultural difference in study population. Most of the women in our society probably accept the post-partum hair loss as natural phenomenon or due to added responsibility of child do not come forward for their own problems. Various causes for hair loss reported in various studies like stress, drugs, thyroid dysfunction, anemia, childbirth/abortion, hormonal imbalances were also found in our study. In our study mild anemia was present in majority of study population (68%) which could be coincidental finding or added factor for hair loss. As per study Bentley et al 15 in Indian women, 46.5% women of child bearing age were having mild to moderate anemia. As per Family welfare statistics in India , 44% women registered under antenatal care program were found to have Hemoglobin level below 11gm%. Although moderate to severe anemia in 19% patients in our study could have hair loss related to anemia; we could not find any significant association with serum ferritin level in our study. Sinclair reported similar finding in his study. 12 Even relation of anemia with hair loss is not statistically significant in present study. Amongst the rarer causes of hair loss, it is interesting to note that in CA group, apart from Discoid LE and pseudopelade of Brocq which is commonly found in other studies also, we found one patient with CA related to Brunsting Perry type of Bullous pemphigoid which is very rare disorder. In TA, hair straightening was factor responsible for hair loss in one patient, apart from trichotillomania associated with mental disorder. Untreated Secondary syphilis associated diffuse hair loss was detected in one patient and one patient was detected having unsuspected HIV serology positivity. In patients who were suspected of having hormonal imbalance, investigations revealed 16.66% patients having significant hormonal imbalance which could be associated with hair loss. Trichogram done in all patients by using standard technique revealed diagnostic findings in 60% patients and served as simple yet effective diagnostic aid in cases of diffuse hair loss. 35 Int J Res Med. 2014; 3(4);28-36 e ISSN: p ISSN:

9 Thus to conclude diffuse hair loss in female 7. Santamaria JR, Spoladore R, Ribeiro patients requires accurate history, clinical AM. An bras Dermatologia, examination and investigations to arrive at 1992;67(4): diagnosis. There could be multiple factors 8. Lee HJ, Kim JW. Assessment of the acting upon in one patient which need to be Association of Iron deficiency and delineated before starting treatment. Frequencies of Autoantibodies and Investigating patients for hair loss which is Abnormal Thyroid function tests in generally regarded as more of a patients with alopecia areata. Korean J psychological importance; could lead to Dermatol. 2002;40(1):8-13. finding of many underlying disorders like 9. Jain VK, Kataria U, Dayal S. Study of anemia, connective tissue disease, syphilis, diffuse alopecia in females. Indian J polycystic ovarian syndrome etc. Only Dermatol Venereol Leprol 2000;66:65- thorough accurate diagnosis; targeted 68. therapy can be initiated which will give 10. Kantor J, Kessler LJ, Brooks DG, satisfactory results. Cotsarelis G. Decreased serum ferritin is REFERENCES associated with alopecia in women. J 1. Stedman s Medical Dictionary,27 th ed. Invest Dermatol 2003;121: Lippincott Williams, Baltimore. 11. Bergfeld WF. Diffuse hair loss in 2005:50. women. Cutis. 1978;22(2): Hadshiew IM, Foitzik K, Arck PC, Paus 12. Sinclair R. There is no clear association R. Burden of hair loss: stress and the between low serum ferritina and chronic underestimated psychological impact of diffuse telogen hair loss. Br J Dermatol telogen effluvius and androgenetic 2002;147: alopecia. Journal of Investigative 13. Eckert J, Church RE, Ebling FJG: Hair Dermatology 2004;123: loss in women. Br J Dermatol 3. Dawber R, Van Neste D. Hair and Scalp 1967;79: Disorders. Common Presenting Signs, 14. Rustom A, Pasricha JS. Causes of Differential Diagnosis and Treatment, diffuse alopecia in women. Indian J 2nd edn. Martin Dunitz, Taylor & Dermatol Venereol Leprol 1994; 60:266- Francis group, London and New 71. York, 2004: Bentley ME, Griffiths PL. The burden of 4. Rushton DH. Management of hair loss in anemia among women in India. women. Dermatol Clin. 1993;11(1):47- European Journal of Clinical 53. Nutrition 2003; 57: Dhruat R, Saragoi P. Hair Evaluation 16. Family welfare statistics in India, 2011 Methods: Merits and Demerits Int J by Statistics Division, Ministry of Health Trichology. 2009;1(2): and family welfare, Government of 6. Chamberlain AJ, Dawber RP. Methods India. Website - of evaluating hair growth. Australas J Dermatol. 2003; 44(1):10-8. fault/files/statistical_information/family %20welfare%20statistics%20in%20Indi a_2011.pdf posted on August Int J Res Med. 2014; 3(4);28-36 e ISSN: p ISSN:

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