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Revista CEFAC

Print version ISSN 1516-1846On-line version ISSN 1982-0216

Rev. CEFAC vol.17 no.6 São Paulo Nov./Dec. 2015

http://dx.doi.org/10.1590/1982-021620151761815 

ORIGINAL ARTICLES

Quality of life and voice in chronic pulmonary disease

Bruna Franciele da Trindade Gonçalves1 

Fernanda Machado Mello1 

Cintia da Conceição Costa1 

Marisa Bastos Pereira1 

Renata Mancopes1 

1Universidade Federal de Santa Maria/UFSM, Santa Maria, RS, Brasil.

ABSTRACT:

Purpose:

analyzing the quality of life related to self-reported voice by individuals with Chronic Pulmonary Disease.

Methods:

cross, exploratory and quantitative study with information obtained from the application of Quality of Life and Voice questionnaire with users an integrated physiotherapy clinic in a university hospital in the interior of Rio Grande do Sul, in the period from March to November 2012.

Results:

19 subjects participated in the study, 12 (63.20%) were males and 7 (36.80%) were females. On the age group, 14 (73.70%) were adults and five (26.30%) elderly, a statistically significant difference. As for the Chronic Pulmonary Disease, ten (52.60%) had bronchiectasis, six (31.60%) had Chronic Obstructive Pulmonary Disease and three (15.80%) asthma. The average of Quality of Life and Voice questionnaire was 85.8 ± 5.8 points. There was no statistical difference between the three areas of Quality of Life and Voice questionnaire and the genre, age and medical diagnosis.

Conclusion:

percentage predominance of males and adult-aged age group, the latter being statistically significant and medical diagnosis of bronchiectasis. The average of the total questionnaire was 85.8 ± 5.8 points. There was no statistical significance in the comparison in questionnaire areas with the genre, age and lung disease. This can be explained by the development of communication strategies in order to minimize the effects of the Chronic Pulmonary Disease on voice. We suggest the completion of other studies addressing the same theme, but with larger samples to check the statistical significance of the studied variables.

KEYWORDS: Voice; Quality of Life; Chronic Obstructive Pulmonary Disease; Bronchiectasis; Asthma

Introduction

Chronic lung disease is characterized by the presence of respiratory diseases in the airways, which can affect other structures besides the lungs and is associated with morbidity and mortality, with significant interference with quality of life 1. The main chronic lung disease (CLD) stand out from asthma, respiratory allergies, occupational lung disease, bronchiectasis, pulmonary hypertension and the most commonly found, chronic obstructive pulmonary disease (COPD) 2.

Some lung diseases present as a symptom, dyspnea, which is a respiratory alteration and is associated with decreased quality of life of individuals, being progressive to the extent of the disease grievance 3).(4. Authors point out that in the manifestation of this symptom suggests a commitment of approximately 50% of lung capacity (LC) 5, which may influence negatively in communication due to use of LC in voice production.

The vocal production can be altered in subjects with lung diseases since the reduction of LC may decrease other measures such as vital capacity and maximum phonation time, essential for proper vocal production 6)-(8. This fact occurs because the pulmonary disorders cause changes in the air stream, which results in a destabilization of the aerodynamic forces of the lungs and the larynx myoelastic, which interferes with the transmission of speech and increases the number of pauses in speech, reflecting negatively on the communication 7, requiring adequate speech evaluation of the voice.

The voice evaluation aims to determine the vocal behavior and identify possible factors that may cause or aggravate the vocal and/or laryngeal changes. This procedure is essential so it can make the diagnosis by correlating the data and subsequently the appropriate therapeutic intervention 7.

There are many ways to measure the voice changes called dysphonia, however, currently it has taken into consideration the impact that these ways generate on quality of life, which is defined as the perception that the individuals have in relation to their position in life, in the context of culture and value system, and in relation to their goals, expectations, standards and concerns 9.

In Brazil, to date, three protocols have been validated for this purpose: Voice-Related Quality of Life (V-RQOL), Voice Activity and Participation Profile (VAPP), and the Voice Handicap Index (VHI), 10. In particular, the use of the questionnaire of quality of life and voice is seen as a non-invasive tool that can detect and quantify the real commitment due to vocal changes in subjects' lives 7),(10)-(13.

V-RQOL is an easy application protocol because it is composed of 10 questions covering physical and socio-emotional factors as well as being self- evaluation and sensitive to individual perceptions, this protocol is validated in Brazil 7),(10)-(12. Still, applying of it helps in understanding the real impact on quality of life that the disease causes in personal, social and professional relationships14.

Studies are found in the literature using V-RQOL protocol in Parkinson's disease, dysphonia abducting15) , spasmodic dysphonia16 in teachers14),(17), choristers18, elderly19),(20 and patients after resection of laryngeal tumors T1 and T2 21. However, there are no studies that used the protocol in subjects with a medical diagnosis of CPD.

Given the above, this study aimed to analyze the quality of life related to self-reported voice by individuals with CPD.

Methods

It is a cross-sectional, exploratory, quantitative study, with information obtained from a questionnaire of quality of life and voice with users of an integrated physiotherapy clinic at a university hospital in the interior of Rio Grande do Sul, from March to November 2012.

This study was approved by the Ethics Committee of Universidade Federal de Santa Maria (23081.014977 / 2011-18) and CAAE (Certificate of Presentation for Ethical Consideration) 0302.0.243.000-11 and all individuals previously signed the Consent and Informed (IC), authorizing the use of data from assessments on scientific research, since maintained secrecy about the identity.

The inclusion criteria for participation in the survey were: signing the consent form, medical diagnosis of any chronic lung disease, being in physical therapy care in that service without treatment time limit and having age above 18 years. Exclusion criteria were adopted not completing the inclusion criteria and subjects who had neurological history or have been submitted to surgery in the head and neck region.

The ages of the subjects were classified into age groups according to the health descriptors 22. Thus, the following ages were used: adults middle age (19-64 years) and elderly (over 65 years).

From the application of the inclusion and exclusion criteria, 19 subjects.were selected.

The procedure carried out was the self-assessment of the impact of dysphonia by applying V-RQOL questionnaire. It was applied individually and the questions were read to the participants to enable a better understanding of them and avoid possible embarrassment for those subjects who did not know how to read or else, they had some difficulty related to visual acuity.

V-RQOL questionnaire consists of 10 questions covering physical area (six questions) and socio-emotional area (four questions) 7),(10),(23. The responses were marked with reference to the scale ranging from 1 to 5, being considered as the severity of the problem and the frequency of occurrence for the response.

The responses analysis results of the total score calculation and for each area. To calculate the scores, we used the standard algorithm, which can vary from 0 to 100, so that the closer to 100, considered as suggestive of a better quality of life and close to zero as a poorer quality of life.

After data tabulation, there was a descriptive analysis of data, and statistical analysis using the Mann-Whitney U-test, test the equality of two proportions and the Kruskal-Wallis test. The significance level was 5%.

Results

The study included 19 subjects, 12 (63.20%) were males and 7 (36.80%) were females. As regards the age group, 14 (73.70%) were adults and 5 (26.30%) elderly, with a statistically significant difference.

As for the medical diagnosis presented by the subjects 10 (52.60%) were bronchiectasis, 6 (31.60%) of COPD and 3 (15.80%) of asthma, however, these values were not statistically significant.

Table 1 shows the complete descriptive analysis of three areas of V-RQOL. It can be seen that the three areas variability is low because the coefficient of variation (CV) is less than 50%, demonstrating that the data are homogeneous. The V-RQOL average was 85.8 ± 5.8 points.

Table 1: Complete Descriptive of the Questionnaire Areas 

Legend: CV = coefficient of variation

V-RQOL = Quality of life related to voice

Table 2 shows the comparison regarding genre in the areas of V-RQOL, it was not found statistical significance.

Table 2: Compares the genre in Questionnaire Areas 

CI = confidence interval; V-RQOL = Quality of Life related to Voice

Mann-Whitney Test

Table 3 shows the comparison of V-RQOL areas with variable age, it was not found statistical significance.

Table 3: Compares the Age Questionnaire Areas 

CI = confidence interval; V-RQOL = Quality of Life related to Voice

Mann-Whitney Test

Table 4 illustrates the comparison of medical diagnosis with areas of V-RQOL, without statistical significance.

Table 4: Compares the Diagnostic in Questionnaire Areas 

V-RQOL = Quality of Life related to Voice; COPD = Chronic Obstructive Pulmonary Disease

Kruskal-Wallis Test

Discussion

The study included 19 subjects of both genres percentage predominance of males and adult age group, being the last one statistically significant.

Regarding gender, it is characteristic of each CPD has a prevalence in particular gender, and bronchiectasis predominates more female 24),(25, COPD is prevalent in males 26),(27 and asthma among women 28)-(30. These results go against what the literature refers, for although the sample is composed of CPD found more in females, the gnere was not that prevailed.

As for the age group the findings of this study are in literature meeting since the CPD affect more adult subjects 28)-(30.

Of medical diagnoses presented by the subjects were percentage predominance of bronchiectasis, followed by CPD and asthma. CPD may result in losses on other important functions such as voice, since they affect the respiratory system and compromise the airflow, which actively participates in vocal production, and when compromised, it can change some aspects of speech such as intensity, volume and voice quality 6),(31.

Bronchiectasis is a CPD that causes change in ventilatory mechanics, such as loss of respiratory muscle strength, changes in lung volume and capacity, as a result of abnormal and irreversible dilatation of the bronchi, as a result of the destruction of the walls of the airways due to constant infections and inflammation 25),(32. According to some authors it is presented by different etiologies and may be suppurative and obstructive character 33.

COPD is characterized by a respiratory illness that causes chronic airflow obstruction. Among the causal factors include the inhalation of particles or gases, smoking, occupational dust, and chemical irritants and socio-economic conditions 5),(26. The airflow obstruction in COPD this may lead to lack of coordination of breathing and phonation, making a difficult oral communication of the individual 27.

The search of Cassiani et al. (2013) 27 found that the Maximum Times of Phonation (MTP) of subjects with COPD was significantly lower compared to individuals without the disease, thus, they suggested that subjects require many air charging for the maintenance and at the end of the frase during conversation.

Asthma is a chronic inflammatory disease of the airways in the presence of wheezing, breathlessness, chest tightness and coughing, and these symptoms occur at night or early morning and they are a generalised and variable consequence of airflow intrapulmonary obstruction 28.

Authors show concern about their treatment and influence on V-RQOL in general, as concern that despite the disease have effective treatment, there are a number of negative consequences for the individual affected due to poor control of the disease and lack of self-management guidelines 29. This can be evidenced in the study of these same authors found that to only 9.3% of asthmatic participants had controlled asthma.

In face of the impairment of pulmonary function presented by CPD is possible that the vocal production can be affected and the communication generally change the quality of life, so there is a need to identify the perception of the subjects through the application of quality of life questionnaires related to voice. Some authors emphasize that assess quality of life related to voice not only contributes to the establishment of therapeutic efficacy measures but also assists in the development of new interventions for patients with vocal alterations 34.

Spina et al. (2009) 35 related quality of life and voice to the professional activity and concluded that the degree of dysphonia was related to worseing in the quality of life regardless of profession, justifying the use of the protocol in individuals who do not use their voice as an instrument of work but as a way to establish communication on a day-to-day, in this case in individuals with CPD.

The work of Ugulino, Oliveira, Behlau (2012) 13 examined the relation between the evaluation of the speech therapist and the self-perception of the impact of dysphonia by patients. The authors found that there was a strong correlation but not direct between the perception of professional and patient, being justified by the patient not only analyze the vocal disorder but the physical, social and emotional restrictions.

The application protocols that examine the perception of the presence of dysphonia in the quality of life of the subjects complements clinical evaluation of speech therapist because elucidates important information about the impact of the change in the various sectors of life of the patient, and assists in expanding the clinical view of professional and broader understanding of the problem 13.

In the descriptive complete analysis of the three areas of V-RQOL (Table 1), it may be observed that the three areas the variability was low, and the average of V-RQOL Total was 85.8 (± 5.8 points). This score was lower than that reported for individuals with healthy voices that is 98.0, however, is still within what is considered normal is 66.0 23. The lowest score was found in the physical area (79.7 points), that among the questions are: difficulty in speaking loud or being heard in noisy environments, the air goes fast and ones need to breathe many times while talking and this fact can be explained by respiratory compromise found in CPD. However, this value is as expected which is up 62.7 for subjects with healthy voices.

No studies were found in the literature which has related areas of V-RQOL protocol with CPD. What can be verified is using this with other populations with or without underlying pathology associated as in the work of Fabricio, Kasama, Martinez (2010) 36, the authors investigated the V-RQOL of university professors and found that most teachers had good quality of life related to voice, evaluated by the V-RQOL.

Also Tutya et al. (2011) 14 conducted research with teachers and found lower values of the scores related to the physical area, that is, poor quality of life, probably by the questions posed in this area reflect the difficulties faced by this population. In Oliveira, Augusti, Smith's work (2013) 37, which was conducted with subjects who underwent surgery due to cancer in the head and neck region was also demonstrated lower values in scores related to the physical area, since after removing laryngeal structures the vocal production got hampered, affecting QOL of subjects.

In search of Behlau, Hogikyan and Gasparini (2007) 38 and Ugulino, Oliveira, Behlau (2012) 13, the authors found that individuals with vocal complaints had lower V-RQOL scores when compared to individuals without vocal complaints, evidence of the importance of considering the negative impact of vocal disorders on quality of life of the subjects. These findings suggest that independent of causal factor, whether by incorrect use of the voice, structural resection or CPD presence, the voice may find itself compromised and reflect negatively on quality of life.

In comparison regarding genre in the area of V-RQOL (Table 2) did not present statistical difference between the female and male, which suggests that the involvement of QOL related to voice occurs regardless of genre, although the lowest values were found male, probably because they represent the highest percentage of the sample. In working of Tutya et al. (2011) 14 which was applied V-RQOL in teachers of both genres, it was found that the greatest loss of QOL related to voice found in females, and the authors justify this finding by the percentage prevalence be more than female teachers.

In the comparison of V-RQOL areas with the variable age, most of the study participants were in middle-age adult age range 19-64 years (Table 3), with no statistical significance, that is, for this study, advancing age has not improved or worsened the issue of QOL related to vocal production. However, the literature states that the natural aging result of the interaction of several biological, functional, psychological and social aspects, it is with the voice 19.

Grillo, Penteado (2005) 39 applied the V-RQOL with 120 teachers aged between 23 and 65 and found that 49.2% of the subjects face difficulties to speak strong in noisy environment, pneumophonic incoordination (air goes fast leading to the need to breathe several times while talking) and instability of vocal quality.

In contrast, the work of Gampel, Karsch, Ferreira (2010) 19 conducted with old teachers and not teachers it was found that the values of V-RQOL scores showed statistically significant correlation with the chronological age of the subjects, so that the older is the age, better it was the Total V-RQOL score.

Despite physiological changes occur of vocal production during the aging process and these influence roughly the QOL related to voice 7, when there is some underlying pathology associated, in this case the CPD, QOL may find itself changed by the oral communication commitment 27. In CPD presence presenting as characteristic airflow obstruction, individuals have limited ventilatory capacity with consequent increased of respiratory rate, which may compromise communication 27.

Table 4 shows the comparison of the medical diagnosis with V-RQOL areas, no statistical significance was verified. No studies were found in literature that have applied V-RQOL questionnaire in subjects with CPD to verify the influence of QOL related to voice, which is what this work proposes, hampering the discussion of this finding.

A fact confirmed in the work of Cassiani et al. (2013) 27, the lack of studies in the literature that debated the dynamics phonation and the glottal competence in COPD.

It is possible that the subjects of this sample have developed communication strategies in order to minimize the effects of the CPD or, the small sample size was not sufficient to demonstrate statistical significance.

Conclusion

This work was percentage predominance of males and adult-aged age. As for the medical diagnosis, the bronchiectasis was the predominant lung disease. In the analysis of the three areas of V-RQOL variability was low, and the average of Total V-RQOL was 85.8 ± 5.8 points, showing no negative impact on quality of life.

REFERENCES

1. Ferreira LN, Brito U, Ferreira PL. Qualidade de vida em doentes com asma. Rev Port Pneumol. 2010;16(1):24-55. [ Links ]

2. WHO, World Health Organization. Chronic respiratory diseases. [acessado 2011 mar 23]. Disponível em: http://www.who.int/respiratory/en/. [ Links ]

3. Sociedade Brasileira de Pneumologia e Tisiologia. II Consenso Brasileiro sobre Doença Pulmonar Obstrutiva Crônica - DPOC. J Bras Pneumol. 2004;30(Supl5):S1-S42. [ Links ]

4. Camargo LACR, Pereira CAC. Dispneia em DPOC: Além da escala. J Bras Pneumol. 2010;36(5):571-8. [ Links ]

5. Soares S, Costa I, Neves AL, Couto L. Caracterização de uma população com risco acrescido de DPOC. Rev Port Pneumol. 2010;16(2):237-52. [ Links ]

6. Rossi DC, Munhoz DF, Nogueira CR, Oliveira TCM, Britto ATBO. Relações do pico de fluxo expiratório com o tempo de fonação em pacientes asmáticos. Rev CEFAC. 2006;8(4):509-17. [ Links ]

7. Behlau M, Madazio G, Feijó D, Pontes P. Avaliação de Voz. In: Behlau M. Voz: o livro do especialista. Rio de Janeiro: Revinter; 2004. p. 85-180. [ Links ]

8. Beber BC, Cielo CA, Siqueira MA. Lesões de borda de pregas vocais e tempos máximos de fonação. Rev CEFAC. 2009;11(1):134-41. [ Links ]

9. Division of Mental Health, The World Health Organization Quality of Life-100, World Health Organization, Geneva, Switzerland, 1995. [ Links ]

10. Behlau M, Oliveira G, Moraes L, Ricarte A. Validation in Brazil of self-assessment protocols for dysphonia impact. Pró-Fono R Atual. Cient. 2009;21(4):326-32. [ Links ]

11. Kasama ST, Brasolotto AG. Percepção vocal e qualidade de vida. Pró-Fono R Atual. Cient. 2007;19(1):19-28. [ Links ]

12. Gama ACC, Alves CFT, Cerceau JSB, Teixeira LC. Correlação entre dados perceptivo-auditivos e qualidade de vida em voz de idosas. Pró-Fono R Atual. Cient. 2009;21(2):125-30. [ Links ]

13. Ugulino AC, Oliveira G, Behlau M. Disfonia na percepção do clínico e do paciente. J Soc Bras Fonoaudiol. 2012;24(2):113-8. [ Links ]

14. Tutya AS, Zambon F, Oliveira G, Behlau M. Comparação dos escores dos protocolos QVV, IDV e PPAV em professores. Rev Soc Bras Fonoaudiol. 2011;16(3):273-81. [ Links ]

15. Lopes BP, Graças RR, Bassi IB, Rezende Neto AL, Oliveira JB, Cardoso FEC, Gama ACC. Qualidade de vida em voz: estudo na doença de Parkinson idiopática e na disfonia espasmódica adutora. Rev CEFAC. 2013;15(2):427-35. [ Links ]

16. Morzaria S, Damrose E. A comparison of the VHI, VHI10 and V-RQOL for measuring the effect of botox therapy in adductor spasmodic dysphonia. J Voice. 2012;26(3):378-80. [ Links ]

17. Pizolato R, Cornacchioni MR, Meneghim M, Bovi GA, Mialhe F, Pereira A. Impacto n quality of life in theachers after educational actions for prevention of voice disorders: a longitudinal study. Health & Quality of Life Outcomes. 2013;11(1):1-9. [ Links ]

18. Penteado RZ, Penteado LAPB. Percepção da voz e saúde vocal em idosos coralistas. Rev CEFAC. 2010;12(2):288-98. [ Links ]

19. Gampel D, Karsch UM, Ferreira LP. Percepção de voz e qualidade de vida em idosos professores e não professores. Ciência & Saúde Coletiva. 2010;15(6):2907-16. [ Links ]

20. Schneider S, Plank C, Eysholdt U, Schützenberger A, Rosanowski F. Voice function and voice-related quality of life in the elderly. Gorontology. 2011;57(2):109-14. [ Links ]

21. Seiferlein EE, Haderlein TT, Schuster MM, Gräbel EE, Bohr CC. Correlation between coping strategies and subjective assessment of the voice-related quality of life of patients after resection of T1 and T2 laryngeal tumours. European Arquives of Oto-Rhino-Laringology. 2012;269(9):2091-6. [ Links ]

22. Descritores em Ciências da Saúde - DeCS, 2014. Disponível em: http://decs.bvs.br/ [ Links ]

23. Gasparini G, Behlau M. Quality of Life: Validation of the Brazilian Version of the Voice-Related Quality of Life (V-RQOL) Measure. J Voice. 2009;23(1):76-81. [ Links ]

24. Seitz AE, Olivier KN, Adjemian J, Holland SM, Prevots R. Trends in bronchiectasis among medicare beneficiaries in the United States, 2000 to 2007. Chest. 2012;142(2):432-9. [ Links ]

25. Zengli W. Bronchiectasis: still a problem. Chin Med J. 2014;127(1):157-72. [ Links ]

26. Sociedade Brasileira de Pneumologia e Tisiologia. II Consenso Brasileiro sobre Doença Pulmonar Obstrutiva Crônica - DPOC. Revisão de alguns aspectos de epidemiologia e tratamento da doença estável. SBPT, 2006. Disponível em: http://www.sbpt.org.br/downloads/arquivos/Consenso_DPOC_SBPT_2006.pdfLinks ]

27. Cassiani RA, Aguiar-Ricz L, Santos CM, Martinez JAB, Dantas RO. Competência glótica na doença pulmonar obstrutiva crônica. ACR. 2013;18(3):149-54. [ Links ]

28. Global Initiative for Asthma. Bethesda: Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2010. [Adobe Acrobat document, 119p.] disponível em: http://www.ginasthma.org/pdf/GINA_Report_2010.pdf. [ Links ]

29. Gazzotti MR, Nascimento AO, Montealegre F, Fish J, Jardim JR. Nível de controle da asma e seu impacto nas atividades de vida diária em asmáticos no Brasil. J Bras Pneumol. 2013;39(5):532-8. [ Links ]

30. Marchioro J, Gazzotti MR, Nascimento AO, Montealegre F, Fish J, Jardim JR. Nível de controle da asma e sua relação com o uso de medicação em asmáticos no Brasil. J Bras Pneumol. 2014;40(5):487-94. [ Links ]

31. Chaves RD, Carvalho CRF, Cukier A, Stelmach R, Andrade CRF. Indicadores de disfagia na doença pulmonar obstrutiva crônica. In: Andrade CRF, Limongi SCO. Disfagia: prática baseada em evidências. São Paulo: Savier, 2012. p. 151-66. [ Links ]

32. Guimarães FS, Moço VJ, Menezes SL, Dias CM, Salles RE, Lopes AJ. Efeitos da ELTGOL e do Flutter(r) nos volumes pulmonares dinâmicos e estáticos e na remoção de secreção de pacientes com bronquiectasia. Rev Bras Fisioter. 2012;16(2):108-13. [ Links ]

33. Zanchet RC, Magalhães AC, Correia AF, Feijó G. A influência de bactérias patogênicas na transportabilidade do escarro e na qualidade de vida de portadores de bronquiectasia. Rev Bras Fisioter. 2006;10(4):457-63. [ Links ]

34. Aaby C, Heimdal J. The voice-related quality of life (V-RQOL) measure a study on validity and reliability of the Norwegian version. J Voice. 2013;27(2):29-33. [ Links ]

35. Spina AL, Maunsell R, Sandalo K, Gusmão R, Crespo A. Correlação da qualidade de vida e voz com atividade profissional. Braz J Otorhinolaryngol. 2009;75(2):275-9. [ Links ]

36. Fabrício MZ, Kasama ST, Martinez EZ. Qualidade de vida relacionada à voz de professores universitários. Rev CEFAC. 2010;12(2):280-7. [ Links ]

37. Oliveira IB, Augusti ACV, Siqueira DM. Avaliação de voz e qualidade de vida após laringectomia supracricóide. ACR. 2013;18(4):353-60. [ Links ]

38. Behlau M, Hogikyan ND, Gasparini G. Quality of life and voice: study of a brazilian population using the voice-related quality of life measure. Folia Phoniatr. 2007;59:286-96. [ Links ]

39. Grillo MHMM, Penteado RZ. Impacto da voz na qualidade de vida de professore(a)s do ensino fundamental. Pró-Fono R Atual. Cient. 2005;17(3):321-33. [ Links ]

Source of help: CAPES

Received: February 05, 2015; Accepted: May 04, 2015

Conflict of interest: non-existent

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