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Pelvic Health IN WOMEN

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Title: Pelvic Health IN WOMEN


1
Pelvic Health IN WOMEN
  • Beth Lonberger, APRN, Family Nurse Practitioner
  • Julie Starr, APRN, Family Nurse Practitioner
  • University of Missouri Hospital and Clinics
  • Womens and Childrens Hospital
  • Center for Female Continence and Advanced Pelvic
    Surgery

2
objectives
  • The participant will be able to
  • Define pelvic health in the female
  • List common diagnosis contributing to pelvic
    floor dysfunction
  • Understand how pelvic organ prolapse, recurrent
    UTI and constipation effect bladder/bowel
    function
  • Discuss treatment options for pelvic floor
    dysfunction

3
PELVIC HEALTH
  • Urinary continence
  • Voiding less than 9xday and 0-1xnight
  • Absence of infection
  • Complete emptying of rectum every day
  • Adequate support of pelvic organs
  • Well estrogenized vaginal tissue
  • Sexual wellbeing

4
COMMON DIAGNOSIS CONTRIBUTING TO PELVIC FLOOR
DYSFUNCTION
  • Urinary Dysfunction
  • Urinary Incontinence
  • Urinary urgency/frequency
  • Nocturia
  • Defecatory Dysfunction
  • Constipation
  • Fecal Incontinence
  • Pelvic Floor Dyssynergia
  • Pelvic Organ Prolapse
  • Levator Ani Muscle Spasm
  • Pelvic Pain
  • Dyspareunia
  • Urinary urgency/frequency/incontinence
  • Obstructive outlet defecation

5
Urinary Incontinence
  • Stress Urinary Incontinence
  • Coughing, Laughing, Sneezing, Lifting, Walking
  • Urge Incontinence
  • Urgency, Frequency, Triggers, Nocturia
  • Overflow Incontinence
  • Retention, Obstruction
  • Functional Incontinence
  • Frail, Decreased mobility

6
Prevalence
7
stress incontinenceTreatment Options
  • Surgical
  • Midurethral sling
  • Bulking agents
  • Nonsurgical
  • Pessary
  • Femsoft urethral insert
  • Pelvic floor physical therapy

8
Urge Incontinence Treatment Options
  • Behavior modification
  • Bowel regimen
  • Premarin vaginal cream
  • Medications
  • Pelvic floor physical therapy (intracavity estim)
  • PTNS
  • Sacral Neuromodulation (Interstim)

9
URINARY FREQUENCY
  • Voiding gt8 times during the day
  • Negatively effects quality of life, especially
    when associated with incontinence.
  • Social isolation
  • Depression
  • Inactivity contributes to more serious health
    problems

10
NOCTURIA
  • GETTING UP MORE THAN ONCE IN THE NIGHT TO VOID
  • Causes
  • Recurrent UTIs, chronic renal failure, congestive
    heart failure, cystitis, diabetes, excessive
    fluid intake, elevated Ca level, sleep apnea.
  • Increase risk of falls
  • Disrupted sleep cycles
  • Treatment Imipramine 25-50mg q hs. Take Diuretic
    at noon.
  • Gillen, L., Marinkovic, L., Stanton, S. Managing
    Nocturia. BMJ. 20043281063-1066.

11
Recurrent UTI
  • SYMPTOMS UTI
  • Urinary urgency/frequency, incontinence,
    dysuria, low back pain, delirium.
  • Elderly often asymptomatic
  • DIAGNOSIS RECURRENT UTIs
  • Three or more UTIs in the past year or gt2 in the
    past six months
  • In and out cath specimen culture positive
  • Cunha, BA, Tessler, JM, Bavaro, MF. Urinary
    Tract Infection, Females. Medscape. October, 19,
    2009.

12
UROGENITAL ATROPHY
  • Vaginal atrophy (atrophic vaginitis) is thinning
    and inflammation of the vaginal walls which
    occurs after menopause due to a decline in
    estrogen.
  • Results in vaginal dryness, itching, burning and
    inadequate lubrication.
  • Urinary symptoms include urgency/frequency,
    incontinence and recurrent UTIs.
  • Pinkerton, J. Vaginal impact of menopause-related
    estrogen deficiency. OBG Management. 2010
    S11-16.

13
UROGENITAL ATROPHY
  • TREATMENT
  • Premarin vaginal cream 0.625
  • ½ applicatorful 3 x week at bedtime for 4-6 weeks
  • then decrease to ½ applicatorful 1xweek at hs
    for maintenance dose
  • Estring (Estradiol vaginal ring)
  • Vaginal ring containing 2mg of Estradiol
    releasing 0.75mcg in 24 hour period
  • To be changed every 90 days

14
DEFECATORY DYSFUNCTION
  • Refers to a multitude of complaints that may
    include having frequent and uncomfortable
    sensations to have a bowel movement, constipation
    or the feeling of poor emptying, and leakage of
    gas/ diarrhea/ and/or solid stool.
  • 20 of women suffer from defecatory
    dysfunction. Among women with pelvic floor
    disorders, the prevalence of defecatory
    dysfunction was 60.
  • Whitcomb, E. Lukacz, E. Lawrence, J. Nager,
    C. Luber, K. Prevalence of Defecatory
    Dysfunction in Women with and Without Pelvic
    Floor Dysfunction. Journal of Pelvic Medicine
    Surgery. 15(4)179-187, July/August 2009.

15
Defecatory Dysfunctioncauses
  • Incomplete emptying
  • Rectocele or perineal rectocele
  • Pelvic floor muscle (Levator ani) spasm
  • Sphincter incompetence
  • Thickening of IAS and thinning of EAS
  • Diet
  • Dehydration
  • Medications
  • Decreased sensation
  • Irritable Bowel Syndrome

16
Defecatory Dysfunctiontreatment
  • Bowel regimen (constipation, diarrhea)
  • Pessary (rectocele)
  • Pelvic floor therapy
  • Behavior modification
  • Do not resist the urge to defecate
  • Proper hydration
  • Dietary changes
  • Medication changes
  • Exercise

17
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18
Fecal incontinence
  • 6 of women lt40 years old
  • 15 of women gt40
  • Nursing Home residents 45-47
  • 7 of all women have fecal smearing
  • 50 of affected women keep FI a secret
  • Ashima Makol Madhusudan Grover William E
    Whitehead. Fecal Incontinence in Women Causes
    and Treatment. Women's Health. 20084(5)517-528. 

19
FECAL INCONTINENCETREATMENT
  • Behavior modification/dietary changes
  • Metamucil daily and Immodium prn
  • Pelvic floor therapy
  • Surgical options
  • Sphincteroplasty
  • 5 year recurrence rate
  • Up to 60

20
PHARMACOLOGICAL MANAGEMENT
  • Metamucil daily
  • Loperamide prn
  • 1 tab (2mg/tab) before each meal and bedtime up
    to 8 tabs/day
  • 2 tabs (2mg/tab) at q meal and hs up to 16
    tabs/day
  • Diphenoxylate with atropine sulfate prn
  • 1 tab (2.5mg/tab) at q meal and hs up to 8 tabs
  • 2 tabs (2.5mg/tab) at q meal and h.s up to 8
    tabs/day
  • Bismuth subsilicylate prn
  • 1-2 tabs (262mg/tab) before meals and h.s. not to
    exceed 4.2 g/day

21
Pelvic floor muscles(Levator Ani complex)
  • Pubococcygeus
  • Coccygeus
  • Ileococcygeus
  • This group of muscles acts as a single
    neuromuscular unit to assist with proper support
    and function of the pelvis organs including
    normal urinary and fecal continence as well as
    genitourinary and rectal support.

22
PELVIC FLOOR (LEVATOR ANI) SPASM
23
LEVATOR ANI SYNDROME
  • A COLLECTION OF SYMPTOMS AND FINDINGS
  • The most common symptoms include
  • Deep dull aching in the rectum/vagina
  • Referred pain to the pelvis, thigh and buttock
  • Pain worsens with sitting and bowel movements
  • Spasms and pain in the pelvic floor muscle
  • Pain during or after intercourse
  • Urinary urgency/frequency possibly incontinence
  • Constipation
  • Prior testing usually rules out other pathologies

24
PELVIC FLOOR MUSCLEASSESSMENT
25
PELVIC FLOOR MUSCLE SPASMASSESSMENT
  • LEVATOR ANI COMPLEX
  • Palpate 4-5 oclock and 7-8 oclock positions
  • INTERNAL OBTURATOR
  • Palpate 2 oclock and 10 oclock positions
  • Single digit palpation of spastic muscle
  • feels like a guitar string or hard object
  • reproduces the pain

26
PELVIC MUSCLE SPASMTREATMENT
  • PELVIC FLOOR PHYSICAL THERAPY
  • Pelvic floor muscle exercises 4 x day
  • Biofeedback
  • Vaginal E-stim
  • BEHAVIOR MANAGEMENT
  • Warm baths/heat daily
  • Yoga/daily stretching/Tai chi
  • Relaxation/stress management/counseling
  • MEDICATIONS
  • Flexeril 5-10mg tid prn
  • Ultram 50-100mg BID
  • Valium suppositories 10mg vaginally bid prn
  • Antidepressent/antianxiety agent

27
Pelvic Floor Therapy
28
Pelvic Floor TherapyComponents
  • Abdominal EMG
  • Measure use of accessory muscle
  • Vaginal EMG
  • Measure resting tone
  • Anorectal manometry
  • Measure muscle strength
  • E-stim (vaginal or rectal)
  • Neuromuscular stimulation (NMS)

29
pelvic floor therapyBenefits
  • Promotes pelvic floor muscle awareness
  • Strength training
  • Electric stimulation
  • enhances muscle awareness and strength
  • increases urethral closure pressure
  • relaxes spasm
  • 4-6 sessions of therapy
  • Folkerts, D., Wood, K. Overactive bladder and
    urinary incontinence A multitherapy approach to
    treatment. Sexuality, Reproduction Menopause.
    4(2), 2006.

30
INDICATIONS
  • Urge Incontinence
  • Stress Incontinence
  • Fecal Incontinence
  • Pelvic Muscle Spasm
  • Pelvic Floor Dyssynergia
  • Pelvic Floor Muscle Weakness

31
PATIENT REQUIREMENTS
  • Cognitive awareness
  • Active participation
  • At least partial innervation of PFM

32
Pelvic Floor Muscle EMG
  • At rest, continuous baseline activity
  • consists of motor unit potentials of
  • 2-4 MicroVolts

33
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34
Anorectal Manometry
  • Air filled balloon placed in the rectum
  • Records squeeze pressure of Levator Ani
  • Can pick up valsalva and register as pressure
  • Manometry is measured from zero
  • Best for measuring true strength of muscle

35
Anorectal manometryinitial visit
36
Anorectal ManometryFinal visit
37
Abdominal EMG
  • PURPOSE
  • To a assist in isolation of
  • pelvic floor muscles
  • To monitor contraction of abdominal
    muscle as an accessory muscle

38
Duel Channel EMG
39
VAGINAL EMGINITIAL VISIT
40
VAGINAL EMGTHIRD VISIT
41
Intracavity Stimulation(e-stim)
  • Inhibits involuntary detrusor contractions
  • Increases bladder capacity
  • Decreases the intensity of urge sensation
  • Decreases pelvic floor muscle spasm
  • Increases urethral closure pressure

42
VAGINAL/RECTAL E-STIM
  • Increases muscle
  • Recruitment
  • Strength
  • Awareness

43
ELECTRICAL STIM MECHANISM
44
NEURAL MECHANISMS INVOLVED IN BLADDER INHIBITION
45
NEUROMECHANISM INVOLVED IN URETHRAL CLOSURE
46
Mechanism of Action
  • Produces a reflex muscle contraction
  • Contracts pelvic floor muscles
  • Relaxation and inhibition of detrusor

47
Pelvic Muscle ExerciseEssentials
  • Muscle Awareness
  • Activation Promotes Function
  • Must have regular exercise
  • Avoid accessory muscles
  • Overload Principle
  • Progression

48
Methods of Teaching
  • HOLDING BACK GAS
  • Stopping urine stream
  • Contracting vagina
  • Contracting rectum

49
HOME EXERCISE PROGRAM
  • Usually 4x per day
  • More frequent with less repetitions for very weak
    muscle.
  • Too much exercise will fatigue muscle and worsen
    symptoms.

50
Pelvic Organ Prolapse
  • Uterine Prolapse (uterus)
  • Cystocele (bladder)
  • Rectocele (rectum)
  • Perineal Rectocele (perineum)
  • Enterocele (vagina)

51
PELVIC ORGAN PROLAPSE
  • http//www.bardurological.com/pop-q/pop-q.aspx

52
Conservative Management of Pelvic Organ Prolapse
  • Bowel Program
  • Vaginal Estrogen
  • Pessary

53
Pessary
  • Vaginal support device for relief of symptoms of
    pelvic organ prolapse
  • Indicated for women who do not desire surgery or
    are not good surgical candidates
  • 92 satisfaction after 2 months
  • Improvement of prolapse in 21 of patients after
    1 year.
  • Success is in patient selection
  • Physical exam

54
Types of Pessaries
55
PESSARY MANAGEMENT
  • Proper fitting may require more than one visit
    every 2-3 weeks.
  • Patient can be instructed on managing their
    pessary at home or return to clinic every 1-3
    months for removal/reinsertion and exam.
  • Estring can be replaced at this time

56
ETHEL
  • HPI Ethel is a 90 y/o with complaints of over
    active bladder x 2 years. Her bladder symptoms
    worsened with recent sacroplasty. She describes
    symptoms of stress incontinence,
    urgency/frequency and urge incontinence which
    worsened at night. She wears a Depends pad and a
    large Poise pad and changes this ensemble 5 x day

57
HPI cont.
  • On an average day she drinks 3 glasses of water,
    2 glasses of juice, 1 cup of coffee and 1 soda.
  • She reports 4 UTIs in the past year.
  • She takes Miralax every morning and reports
  • 1-2 bowel movements per day and strains at stool.
  • 24 hour pad weight 803 grams
  • Bladder diary indicates 16 voids/24 hours
  • She gets up 4 x night to void.

58
MEDICAL/SURGICAL HISTORY
  • Patient reports conditions of HPTN, anemia,
    hernia, sinusitis, GERD, hypothyroidism,
    Raynauds syndrome, constipation-predominant
    irritable bowel syndrome.
  • Surgical history includes sacroplasty,
    cholecystectomy, appendectomy, hysterectomy and
    ovariectomy.

59
DIAGNOSIS
  • Stage II rectocele
  • Perineal rectocele
  • Defecatory dysfunction
  • Urogenital atrophy
  • Urinary urgency/frequency
  • Urge incontinence
  • Stress incontinence
  • Urinary tract infection
  • Recurrent urinary tract infections

60
TREATMENT PLAN
  • Bowel regimen for her defecatory dysfunction.
  • Premarin vaginal cream for urogenital atrophy.
  • Fosfomycin 1 x dose to treat UTI.
  • Trimethoprim 100mg q hs for recurrent UTIs.
  • Oxybutynin prn for OAB.
  • Pelvic floor therapy x 5 sessions.
  • Imipramine 25mg q hs for nocturia.

61
OUTCOME
  • Patient reported 100 improvement after 5
    sessions of pelvic floor therapy.
  • She voids 7-8 x day and 2 x night.
  • Her daytime incontinence completely resolved and
    she leaks only drops during the night.
  • She wears a panty liner for peace of mind.
  • She remains on Trimethoprim at bedtime.
  • She remains on Imipramine q hs.
  • She takes Oxybutynin only when going out.

62
OUTCOME cont
  • She continues with Premarin vaginal cream 1 x
    week.
  • She continues to do pelvic floor exercises 4 x
    day.
  • She takes Metamucil daily and reports 1-2 bowel
    movements per day without straining.
  • She just returned from a vacation with her family
    in which they drove over 500 miles in the car.

63
PATRICIA
  • Patricia is a 78 y/o patient with a lifelong
    history of diarrhea predominant irritable bowel
    syndrome. She presents with symptoms of fecal
    incontinence for the past year. She reports
    leaking stool five minutes after she starts to
    exercise.
  • She reports 1-2 bowel movements per day and
    strains at stool.

64
HPI cont
  • Her urinary complaints include only mild stress
    incontinence.
  • She wears a panty liner for peace of mind.
  • She denies urinary urgency/frequency and gets up
    1-2 times per night to void.
  • She describes a burning perineal pain after
    intercourse and a soreness which lasts several
    hours.
  • She uses Estrace cream for vaginal dryness.

65
MEDICAL/SURGICAL HISTORY
  • Osteoporosis, diverticulosis and diarrhea
    predominant irritable bowel syndrome.
  • G2P2 SVDx2 with largest birthweight 8 13oz
  • Surgical history includes hysterectomy, cystocele
    repair, cataract repair.

66
DIAGNOSIS
  • Diarrhea predominant IBS
  • Fecal incontinence
  • Defecatory dysfunction
  • Stress incontinence
  • Stage I cystocele
  • Stage I rectocele
  • Lichen planus (bx positive)

67
TREATMENT
  • Metamucil and Loperamide for treatment of
    defecatory dysfunction/IBS
  • Continue Estrace cream for urogenital atrophy
  • Clobetasol ointment for lichen planus
  • Pelvic floor therapy x 4 sessions for fecal
    incontinence.

68
OUTCOME
  • Patient reports 100 improvement in her fecal
    incontinence after 4 sessions of pelvic floor
    therapy.
  • She reports 1 stool/day without straining with
    daily use of Metamucil.
  • She is able to eat fruits and vegetables without
    GI complaints for the first time in years
  • Her perineal burning/soreness have resolved.
  • She exercises daily and no longer wears a pad.

69
LORI
  • HPI Lori is an 18 y/o G0 with history of sexual
    abuse starting at the age of 7. She was recently
    treated by Dr. Courtney Barr at the Center for
    Vulvar Diseases for vulvodynia which she reports
    is completely resolved.
  • She describes an intermittent, stabbing LLQ
    pelvic pain which occurs 5-6 x day.
  • She reports urinary urgency/frequency and mild
    urge incontinence.

70
HPI cont
  • She often has a sensation that she is not
    emptying her bladder completely.
  • Lori reports bowel movements every other day and
    strains at stool.
  • She is not sexually active at this time.

71
MEDICAL/SURGICAL HISTORY
  • Patient describes history of asthma and
    headaches.
  • Surgical history negative.

72
DIAGNOSIS
  • Urinary urge incontinence
  • Defecatory dysfunction
  • Levator spasm

73
TREATMENT PLAN
  • Bowel regimen for her defecatory dysfunction.
  • Pelvic floor therapy for levator spasm.

74
OUTCOME
  • Patient reports 100 improvement in her symptoms
    after 4 sessions of pelvic floor therapy.
  • She takes a daily dose of Metamucil and reports
    one bowel movement per day without straining.
  • Her pelvic pain is completely resolved.

75
SHELBY
  • HPI
  • 24 y/o G0, RLQ pain for 9 months, appendectomy, 9
    negative MRIs/CTs/Ultrasounds, seen in multiple
    clinics, ER throughout mid-MO
  • Pain 8-9/10, worse when moving around, improved
    with rest and heating pad
  • Urgency, urge incontinence (pad), sense of
    incomplete bladder emptying

76
HPI cont.
  • Severe constipation with 1-2 BMs weekly
  • Bloating
  • Pain with intercourse
  • Worried about serious problem with ovary

77
MEDICAL/SURGICAL HISTORY
  • Migraines
  • Hypothyroid
  • Appendectomy

78
DIAGNOSIS
  • Urinary urgency
  • Urge Incontinence
  • Defecatory Dysfunction
  • Severe Levator spasm
  • Dyspareunia

79
TREATMENT PLAN
  • Bowel Regimen
  • Home Exercises
  • 4-6 sessions of PFT with estim
  • Heat therapy
  • Will consider colorectal consult

80
UPDATE
  • Pain improving and started home program of e
    stim.
  • Defecatory dysfunction improving, but still a
    problem, BM every 2-3 days

81
ANNE
  • HPI Anne is a 70 y/o G2P2 with complaints of
    stress incontinence, urgency/frequency, urge
    incontinence and nocturia for the past 6-8
    months.
  • She wears a panty liner for protection but not
    every day.
  • She reports one bowel movement every other day
    and strains at stool.

82
HPI cont
  • On an average day she drinks 5-6 glasses of
    water, 1 glass of juice, 1 glass of milk, 2 cups
    of coffee, 1 glass of tea and 1 soda.
  • Her bladder diary indicates she voids 7 x in 24
    hours.
  • Her 24 hour output averages 3400cc.

83
MEDICAL/SURGICAL HISTORY
  • Patient reports no medical problems and has never
    had surgery.
  • She reports two vaginal deliveries with a maximum
    birthweight of 815oz..

84
DIAGNOSIS
  • Stage II cystocele
  • Stage II rectocele
  • Perineal rectocele
  • Nocturia
  • Urodynamic stress incontinence
  • Urge incontinence
  • Urogenital atrophy
  • Defecatory dysfunction

85
TREATMENT
  • Bowel regimen to treat defecatory dysfunction.
  • Premarin vaginal cream for urogenital atrophy.
  • Moderate fluids, especially in the evening.
  • Pelvic floor therapy for urge and stress
    incontinence.

86
OUTCOME
  • Patient reports 85 improvement in her symptoms
    after 6 sessions of pelvic floor therapy.
  • Her urge incontinence has resolved and she
    continues with mild stress incontinence 2-3 x
    month.
  • She continues on Premarin vaginal cream 1 x week
    for urogenital atrophy.
  • She continues with pelvic floor exercises and
    urge suppression techniqes daily.
  • She continues to moderate her caffeine intake.

87
OUTCOME cont
  • Anne was so pleased with her results but her best
    friends bladder was limiting her lifestyle.
  • Her friend completed a course of pelvic floor
    therapy.
  • They have just returned from two weeks in Italy
    and reported complete bladder control and no
    anxiety about being on a tour bus all day?

88
PELVIC FLOOR MUSCLE EXERCISES
How to Identify the Correct Muscle To find the
proper muscle, imagine having to pass gas while
with a group of people. In order not to
embarrass yourself, you squeeze the muscles
around your rectum to hold the gas back. This is
the muscle you want to exercise. Common
Mistakes Never use the muscles in your stomach,
legs, buttocks, and dont hold your breath. To
be sure you are not using your abdominal muscles,
place your hand on your abdomen while you squeeze
the pelvic floor muscle. If you are feeling your
abdomen move, you are also using your stomach
muscle. How to Exercise When exercising it is
important to squeeze and relax your muscles as
prescribed. One work/ rest cycle is one
exercise. If while you exercise you no longer
feel the contraction, the muscle is tired. Stop
and rest for a few minutes and then go back to
the exercises. Where to Exercise These exercises
can be done anywhere at any time. If you are
doing them properly, your legs, stomach, thighs
and buttocks will not move, and no one will know
you are doing your exercises. Do the exercise
sitting or lying down when you first start the
program. After eight weeks you can do them
standing, sitting or lying. Can These Exercises
Harm Me? NO! These exercises cannot harm you in
any way. If you experience back or stomach
discomfort after you exercise, then you are
trying too hard and using extra muscles. Relax,
and start over. Prescribed Exercise Contract the
muscle for 5 seconds, and then relax for 10
seconds (this is one exercise or cycle). Do 5
exercises in a row. Repeat this 4 times each
day. If you perform them with an activity that
you routinely do every day, you will be more
likely to remember them. Mealtimes, bedtime and
driving in the car are very common. New mothers
can perform them while bottle/breast feeding.
Increase the contraction time by one second and
one repetition every two weeks (always continue 4
x day). Your goal is contract for ten seconds,
relax for ten seconds. Do 10 exercises in a row 4
x day.
89
URGE SUPPRESSION TECHNIQUES
  • When you feel the urge
  • Stop what you are doing.
  • Sit down, if it is possible, or stand quietly.
  • Remain still.
  • Rushing to the bathroom may cause you to lose
    control of your bladder.
  • When you are still, the urge is easier to
    control.
  • Squeeze your pelvic floor muscles quickly several
    times. (Contract 2 seconds, relax for one second,
    5-6 times in a row)
  • Relax the rest of your body.
  • Take a few breaths to help you relax.
  • Wait until the urge goes away.
  • Walk slowly to the toilet. Do not rush.

90
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91
Skin care
  • www.kerryskincompany.com

92
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