CirCUit WEigHt trAining or WAlKing EXErCiSE in ElDErlY PAtiEntS

Artigo original
CIRCUIT WEIGHT TRAINING OR WALKING
EXERCISE IN ELDERLY PATIENTS WITH
MEDICATED DIABETES AND HYPERTENSION
Treinamento em circuito com peso ou exercício de caminhada em
pacientes idosas com hipertensão ou diabetes medicadas
abstract
BACKGROUND: There are different types of exercises, but the circuit weight training is less prescribed for the elderly in order
to corroborate the control of glycaemia and hypertension. OBJECTIVE: To compare the acute and chronic effects of circuit
weight training or walking exercises on capillary glucose, physical fitness, and arterial blood pressure of the elderly women.
METHODS: Twelve weeks of circuit weight (n = 14) or walking (n = 9) were performed 3 times a week at the intensity of 40 to
60% heart rate, 11 to 13 in the Borg Scale. The elderly patients with medicated hypertension and diabetes (users of ß-blockers,
angiotensin-converting enzyme inhibitors and oral hypoglycemic) were selected. RESULTS: The capillary glucose decreased in
both groups in acute and chronic effects of exercise (p ≤ 0.05). The systolic blood pressure increased in acute moment only
in the circuit weight (+6 mmHg, p ≤ 0.05) without differences in the diastolic blood pressure. The right handgrip, the balance of
right and left legs, the sitting and standing test were improved in walking (p ≤ 0.05), and flexibility in circuit weight (p ≤ 0.05).
There was no statistically significant difference in the left handgrip, subscapularis, lumbar back, and abdominal circumference,
three-meters walking under line. There was no difference in the comparison between groups. CONCLUSION: The two types of
exercises improve metabolic rehabilitation. Only 12 weeks of the circuit weight training seems to be a short period to induce
higher physical performance in elderly women.
KEYWORDS: aging; blood glucose; physical fitness; rehabilitation.
resumo
Rosilene Andrade Silva Rodriguesa,b, Fabrício Azevedo Voltarellia, Conceição de Maria Moita Machado
de Carvalhoa, Giulia Schaufferta, Waléria Christiane Rezende Fetta, Carlos Alexandre Fetta
INTRODUÇÃO: Existem diferentes tipos de exercícios físicos, mas o de circuito com pesos é pouco prescrito para idosos, a fim
de corroborar no controle da glicemia e da hipertensão. OBJETIVO: Comparar os efeitos dos exercícios em circuito com pesos ou
de caminhada nas fases aguda e crônica sobre glicemia capilar, aptidão física e pressão arterial de mulheres idosas. MÉTODOS:
Foram realizadas 12 semanas de exercícios em circuito com pesos (n = 14) ou caminhada (n = 9), 3 vezes por semana, em
intensidade de 40 a 60% da frequência cardíaca, 11 a 13 na escala de Borg. As pacientes idosas tinham diabetes e hipertensão
medicada (usuárias de substâncias ß-bloqueadoras, inibidores de enzima conversora de angiotensina e hipoglicemiante oral)
foram selecionadas. RESULTADOS: A glicemia diminuiu em ambos os grupos nas fases aguda e crônica do exercício (p ≤ 0,05).
No exercício de circuito com pesos, a pressão arterial sistólica aumentou apenas na fase aguda (+6 mmHg, p ≤ 0,05), sem
diferenças na pressão arterial diastólica. A força de preensão da mão direita, o teste de equilíbrio das pernas direita e esquerda
e no teste de sentar e levantar foram melhorados na caminhada (p ≤ 0,05), e a flexibilidade no circuito com pesos (p ≤ 0,05).
Não houve diferenças estatisticamente significantes na força de preensão da mão esquerda, na subescapular, na lombar e na
circunferência abdominal durante o andar sob linha de três metros. Na comparação entre o exercício de circuito com pesos ou
caminhada, não houve significância estatística. CONCLUSÃO: Os dois tipos de exercícios favorecem a reabilitação metabólica.
Apenas 12 semanas de exercício de circuito com pesos parece pouco tempo para induzir maior desempenho físico em idosas.
PALAVRAS-CHAVE: envelhecimento; glicose sanguínea; aptidão física; reabilitação.
Nucleus of the Studies in Physical Fitness, Computers, Metabolism, Sports and Health, Federal University of Mato Grosso (UFMT) – Cuiabá (MT), Brazil.
Mato Grosso State Health Department (SES-MT) – Cuiabá (MT), Brazil.
a
b
Dados para correspondência
Rosilene Andrade Silva Rodrigues – Avenida França, 442 – Santa Rose – Cuiabá (MT), Brasil – E-mail: [email protected]
DOI: 10.5327/Z2447-211520161022
Elderly patients in physical exercise with diabetes and hypertension
INTRODUCTION
The elderly population is increasing and it is estimated
that there will be two billion people aged 60 years or older
by 2050 in the world, with the majority living in developing
countries.1,2 Therefore, public health intervention by qualified
professionals is necessary to supply this demand, and physical
exercises (PE) can be a good action strategy.3
Diabetes mellitus (DM) is a chronic and degenerative
metabolic disease. It presents multiple etiologies, due to genetic
or environmental factors.4 An increase in DM prevalence may be
the result from changes in dietary intake and lifestyle, whereas
decreased levels are the effect of physical activity and aging
population.4,5 In order to prevent injuries, glucose levels can
be monitored in the elderly during training or rehabilitation
sessions by means of capillary blood glucose (CBG) tests.6
Thus, exercises can be used as a non-pharmacological therapy
in the elderly with DM, together with changes in eating habits, hypoglycemic drugs, or insulin administration.7
Systemic arterial hypertension (AH) is a chronic disease
with high prevalence in the elderly population.8 Studies have
shown that aerobic or resistance exercises are beneficial for
the adult population.9-11 However, lifestyle changes are also
necessary, including good nutrition, body weight control, and
practice of sports and leisure time.10 In addition, it is important
to monitor the heart rate and arterial blood pressure (ABP)
during exercise sessions.11
Due to greater knowledge of the aerobic exercise benefits,
it is prescribed more often and is mentioned by several
studies.12-14 In contrast, the demand for resistance exercises
with weights has increased.10 These have numerous applications
following the objectives for elderly with AH and DM, and it
is associated with the development of physical fitness and
health.13 Aerobic and resistance exercises with weights have
presented beneficial effects in the treatment of DM in adults
aged in average 52 years.15 However, it is unknown whether
circuit weight training (CWT) for 12 weeks is able to yield
similar results in the elderly.
Therefore, it is believed that the indication of both
exercises is important. Several studies have demonstrated
that the pre-hypertensive elderly showed improvement
after six months of regular exercise.9,16 However, it is still
unknown whether these improvements are related only to
CWT exercise, without considering changes in the lifestyle
and diet of such population.13
CWT is rarely practiced due to less prescription by health
professionals (physical therapists and physical educators),
particularly in the elderly population. However, walking
(WLK) is commonly indicated. Therefore, the aims of this
study were to compare the exercises effects with CWT or
2
WLK, the acute and chronic phases of capillary glucose,
physical fitness, and ABP of the elderly medicated women.
MATERIALS AND METHODS
This is an exploratory study with an experimental exercise
protocol. Exercises were conducted in two types and analyzed,
i.e., in acute and chronic phases, in 23 elderly people from
the Padre Firmo Duarte Social Center for Elderly People
(SCE), who were taking medicine like β-blockers, angiotensinconverting enzyme (ACE) inhibitors, and oral hypoglycemic
agents. In this study, the elderly subjects exhibited a high
prevalence of metabolic conditions, especially AH and DM. The
WLK and CWT exercises were prescribed for rehabilitation
due to their low cost. The CWT used free weights as leg
weights, baton of iron, and dumbbells. The proposal was to
exclude weight training with bodybuilding gym equipment.
We selected elderly women with AH and DM who had
been diagnosed 12 months before the study. Participants were
divided into two groups according to the type of exercise:
CWT (n = 14) and WLK (n = 9). All subjects signed the
free informed consent, and the protocol was approved by
the Research Ethics Committee of Julio Müller University
Hospital (number 330/CEP-HUJM).
Inclusion and exclusion criteria
Elderly people with AH and DM, ≥ 60 years of age,
with body mass index (BMI) between 25 and 35 kg/m2, and
attending the SCE facility were included. Carriers of acute
arthritis or osteoarthritis, physical or mental disabilities,
decompensated DM or AH regardless of regular medication
use, cardiopathy with angina at rest, acute inflammatory
diseases or major stroke sequel were excluded. Apart from
the study protocol, subjects were advised not to perform any
kind of exercise programs. In addition, they needed to have
a minimum attendance of 75% at training sessions and to
provide a medical permission to practice exercise. During
the interview, the sociodemographic questionnaire17 and
Lawton’s Instrumental Activities of Daily Living (IADL)
scale18 were applied (0 to 9 points = dependent; 9 to 18 =
partially dependent; and 18 to 27 = totally independent);
physical evaluations (anthropometry and tests) were conducted
before the protocol beginning, and 48 hours after the last
session of training rehabilitation (12 weeks).
Anthropometry measurements
We used a metric tape (Sanny® Made in Fortal, Brazil),
which was not flexible or extensible, with an accuracy of 0.1 cm,
to measure circumferences of waist (WC), abdomen (AbC),
Geriatr Gerontol Aging
Rodrigues RAS, Voltarelli FA, Carvalho CMMM, Schauffert G, Fett WCR, Fett CA
and hip (HC).19 To measure body weight, a set of platform
scales with a stadiometer (Filizola Electronic® Made Oswaldo
Filizola, Brazil) was used, with precision of 0.1 kg and 0.5 cm.
The elderly subjects were weighed with the smallest possible
clothing, and their height was measured standing barefoot,
with the neck, buttocks, and heels touching the stadiometer
of scales.20 The weight and height measurements were used
to calculate the BMI (kg/m2).21
Physical tests
Romberg’s test,22 which consists of walking a three-meter
long line with eyes open (up to two attempts allowed), was
performed. The number of times a person sits down and
stands up23 in 30 seconds (complete movement and sitting
with lumbar back up and standing with knees extended) in
a 43-cm tall chair, which was leaning against the wall and
had a straight back without arms, was calculated. In order
to calculate flexibility, we used Wells’s test,20 which involved
the elderly subject sitting on an exercise mat for two seconds,
maintaining the maximum trunk flexion (the mean of three
attempts was calculated). In addition, we calculated the onelegged stance balance,24 with eyes opened and arms along
the body and without resting hands until balance loss or
till maximum time of 60 seconds (with calculated mean of
the best result in two attempts). The strength of the hand
and subscapularis (range of 0 to 100 kg) and lower limb (0
to 170 kg) was measured using dynamometry (Kratos®).
These strength tests were conducted for six seconds, with
an interval rest of one minute (the mean of three attempts
was calculated).20
Glycemic test and measurement
of arterial blood pressure
The maintenance of eating habits without dietary
modifications was recommended to the elderly people, who
were asked to arrive 15 minutes earlier in order to rest both
for evaluations as well as for doing PE. Blood was aseptically
collected from a finger sterilized with cotton dipped in alcohol
using a lancet. The glycaemia concentration was determined
by reagent strips in a portable glucometer (ONE TOUCH®
Advantage-plus, made Life Scan, Inc., USA), before and after
the PE session. Then, SBP and DBP were measured with
a sphygmomanometer (Solidor® Made São Paulo, Brazil)
and a stethoscope (Rapport® Made Wenzhou Instruments
Co Ltda, China) from the brachial artery of the right arm
in the sitting position (the mean of two measurements was
considered).
The data of pre- and post-PE session denominated acute
effect were measured with the elderly sitting in a room in
CWT or on chairs placed beside the WLK track immediately
after complete training. The chronic effect data were collected
following the training session after the adaptation period and
after 12 weeks of PE. The measurement and assessment were
similar to the chronic phase 48 hours after the last training
session and prior to the re-evaluation of physical tests.
Physical rehabilitation protocol
The use of a shirt customized for the study, of shorts or
sweatpants, and tennis shoes with caps or hats was recommended for WLK. After resting, rate monitors (Polar® Made
Proximus Tecnologia, Rio de Janeiro, Brazil) were placed for
monitoring the ABP and heart rate during the PE.
CWT was composed of 11 seasons, with exercises for each
muscle group, 15 minutes of warm-up and stretching and
45 minutes with weights: 40” weight duration, interspersed
by 30” change over interval. On average, three rounds of a
15-minute circuit each was the minimum performed, with
one-hour duration of PE, totaling 36 sessions over 12 weeks.
The initial weight used was a load of 20% of the lowest measured handgrip dynamometry value (5 kg/f ), which corresponded to 1 kg (Chart 1).
WLK was performed on an appropriate track attached
to the center, with 10 minutes of warming, 40 minutes of
WLK, and 10 minutes of final stretching.
The CWT was done in a covered space with six windows
and ceiling fans in a room of approximately 80 m2. Exercises
VIII-IX-X (Figure 1) performed lying on the mattress
presented no changes during the interval. The CWT sequence
included an initial warm-up in various positions and stretching
for different muscle groups at the end of the training, which
were conducted in the standing, sitting, or lying position
(Figure 1).
Statistical analysis
The sample distribution was determined by ShapiroWilk’s test followed by descriptive statistics to calculate
Chart 1 Weight and materials used for the load during the
physical exercise training.
Materials
15 days of
adaptation
(in kg)
1st
month
(kg)
2nd
month
(kg)
3rd
month
(kg)
Baton or
iron bar
1
2
3
6
Leg
weights
1
2
2
2½
Dumbbells
1
1½
1½
2½
Geriatr Gerontol Aging
3
Elderly patients in physical exercise with diabetes and hypertension
the mean and standard deviation of the analyzed variables. In order to verify the influence of acute and chronic
phases, the exercise on glycaemia values, before and after
intervention of WLK and CWT, the paired Student’s t-test
was applied. In the comparison between WLK and CWT
groups, the unpaired Student’s t-test was used with independent samples, significance of p ≤ 0.05 and 95% confidence interval (CI).
RESULTS
This study found a 62% prevalence of AH and 21% of
DM among the elderly subjects admitted to the SCE. 17%
(n = 23) elderly people with AH and DM were selected for
exercise protocols.
With regard to the IADL, the mean was 25 (± 2) in the
elderly people, and this score classified them at the level of
total independence. The mean waist to hip ratio (WHR) was
0.87 (± 0.05) and the abdominal circumference was 96.27
(± 8.8) cm, which may indicate risk factors for metabolic
diseases (Table 1).
The results show that the pre- and post-interventions in
acute and chronic phases on glycaemia levels were significant
improved (p ≤ 0.05) with either WLK or CWT interventions.
On the other hand, the acute effect of CWT increases the
SBP (p ≤ 0.05), with a non-significant reduction observed
with WLK. No chronic effect from either CWT or WLK
was observed on SBP.
There were improvements in both hand strength (p ≤ 0.05)
and in the 30-second sitting and standing test (p ≤ 0.05),
as well as in the right and left-legged stance test (p ≤ 0.05)
with WLK (but not CWT) training. In the CWT trained
group, there was improvement in flexibility (p ≤ 0.05) measured using Wells’s test of bench. No other variables assessed
ENTRY
EXIT
Eldery in bar wall
Chairs
Mats
Bar iron
XI
III
II
Exercise CWT
I
I-Hread or hammer
II-Squat the bar
III-Development with baton
IV-EWxtension of knee (leg weights)
V-French triceps with dumbbells
VI-flexion knee (leg weights)
VII-Stiff with baton
VIII-Supine with iron bar
IX-Scissors
X-Abdominal
XI-Stretching exercises
IV
VIII
VIII IX X
VII
V
VI
V
CWT: circuit weight training.
Figure 1 Site plan of circuit weight training performed in the social center for elderly with the respective sequence of
exercises for different muscle groups.
4
Geriatr Gerontol Aging
Rodrigues RAS, Voltarelli FA, Carvalho CMMM, Schauffert G, Fett WCR, Fett CA
herein changed acutely or after 12 weeks of rehabilitation
with CWT or WLK training (Table 2).
DISCUSSION
There was a statistically significant reduction in glycaemia levels with both exercise protocols. The result of physical
performance was better in WLK training, probably because
this group presented poorer initial performance than the
CWT group. In addition, elderly people with AH and DM
who used drugs for a longer period had a worse health associated with aging, phase of the rehabilitation, and/or recovery,
which generally took longer for improved fitness physical.
Similarly to the results observed in this study,16 other authors
also reported improvements in both acute and chronic effects
of exercise on blood glucose levels.16 In a study,25 authors also
found significant improvements in glycaemia levels after PE,
with non-CWT. These studies differ from the present study
because they used gym equipment and people were younger.
In the present study, participants aged 60 years or more and
worked out using free-weight device or equipment, such as
barbells, leg weights, batons, and iron bars. However, the progressive load increase was limited during training since we do
not have equipment with adjustable loads.26
Table 1 Characteristics of the elderly selected for intervention.
Intervention subsample (n = 23)
Variables
n (%)
Mean
(± SD)
95%CI
Age (years)
23 (100)
68.00
(5.3)
65.7 – 70.3
Weight (kg)
23 (100)
63.12
(8.10)
59.62 – 66.62
Height (cm)
23 (100)
1.50
(0.05)
1.48 – 1.52
IADL (0 to 27
points)
23 (100)
25.33
(2.4)
24.38 – 26.48
Body mass index
(kg/m2)
23 (100)
27.86
(2.9)
26.6 – 29.12
WHR (W/H cm)
23 (100)
0.87
(0.05)
0.85 – 0.89
Abdominal
circumference (cm)
23 (100)
96.27
(8.8)
92.3 – 100.1
IADL: Lawton’s Instrumental Activities of Daily Living (0 to 9
points = dependent; 9 to 18 points = partially dependent; 18 to 27
points = totally independent); WHR: waist to hip ratio; SD: standard
deviation; CI: confidence interval in 95%; significance of p ≤ 0.05.
In a study performed with middle-aged obese women,
Fett et al.13 noted significant improvements in the physical
performance and biochemical markers after eight weeks of
CWT together with lectures and nutritionist interventions.
In the present study, there were no guidelines as well as nutritional recommendations; this fact, at least in part, may have
influenced the adhesion to the program.27
Improvements in physical fitness were not seen in all
variables in this study. Other researchers reported positive changes.9 Nevertheless, in another investigation, it was
applied a combined exercise circuit session that attenuated
stress blood pressure reactivity in healthy adults.28 Another
hypothesis may be the constant necessity to monitor the
correct use of antihypertensive drugs, which was reported
by caregivers who observed failures in the administration
of these drugs.
The elevation of ABP in the CWT training in acute effect
of exercise on SBP and DBP can be explained by an increased
release of catecholamines,29 with subsequent higher cardiac
output at the end of the training session. However, in the
cumulative effect of exercise, blood pressure levels reduced
but they did not present statistical significance. Even though,
in another study,8 the authors mention the absence of dietary
monitoring, amount of salt intake, regular practice of PE,
difficulties in changing habits and lifestyle, and the need of a
multidisciplinary team in centers for the elderly. But there was
no guidance or prescribed diets in the present study. This could
be an important reason for no observed difference. In addition,
in the study,9 the patients were under medication and in
these conditions, they presented normal blood pressure. It is
relevant to point out that our subjects were under treatment
(antihypertensive and hypoglycemic drugs) and this condition
normalizes the blood pressure and glycemic levels.
The meta-analysis performed by Peterson et al. 30
reported that trained elderly people (three times per week;
17.6 to 24 weeks of training) aging 50 to 92 years showed
improvements of 40 to 85% in relation to muscle strength
tests and 70% in the one-repetition maximum test. After
12 weeks of training, the present study showed that the
intensity chosen by us caused good adherence and no painful
relapses; however, it was not progressive enough for statistical
significance in the CWT group. It increased muscle strength
in the WLK group, which was explained by the admission of
more sedentary elderly people performing this PE protocol.
In the re-test of hand and lumbar dynamometry, although
the same technique was used in both tests, the elderly were
probably not interested in using too much force. This hypothesis
is reinforced by their opinion when they performed it first time
(mainly pain back). Therefore, in the elderly, other types of test
Geriatr Gerontol Aging
5
Elderly patients in physical exercise with diabetes and hypertension
Table 2 Acute and chronic phase exercise on physical performance in circuit weight training and walking in the elderly group.
CWT (n = 14)
WLK (n = 09)#
Variables
Mean (SD)
Acute
Mean (SD)
Chronic
Mean (SD)
Acute
Mean (SD)
Chronic
Weight (kg)
64.12 (8.4)
64.45 (9.6)
61.58 (4.7)
60.92 (7.9)
IADL (points)
25.42 (2.7)
26.0 (1.7)
25.44 (2.0)
25.44 (2.0)
BMI (kg/m2)
27.81 (2.3)
27.9 (2.7)
27.94 (3.7)
27.63 (3.8)
Glycaemia (acute) in mg/dL
102.92 (11.8)
91.54 (11.7)*
98.12 (11.2)
90.62 (10.4)*
Glycaemia (chronic) in mg/dL
91.70 (11.70)
84.21 (10.24)*
96.62 (10.4)
86.25 (5.8)*
SBP (acute) in mmHg
121.43 (11.67)
127.0 (11.38)*
143.3 (11.1)
132.2 (18.5)
SBP (chronic) in mmHg
127.14 (11.3)
130.0 (13.5)
132.5 (18.3)
128.7 (16.4)
DBP (acute) in mmHg
77.85 (5.78)
77.14 (6.11)
84.44 (13.33)
81.11 (12.69)
DBP (chronic) in mmHg
77.85 (5.78)
77.14 (6.11)
81.11 (12.69)
80.0 (11.18)
Hand grip right (kg/f)
22.16 (4.1)
22.36 (4.49)
15.47 (7.5)
19.22 (6.3)*
Hand grip left (kg/f)
19.28 (4.1)
19.80 (4.80)
17.80 (3.9)
19.11 (2.9)*
Subscapularis (kg/f)
12.10 (3.9)
10.76 (2.9)
8.97 (4.1)
10.25 (3.0)
49.2 (15)
50.92 (12)
45.5 (17)
41.1 (12.6)
Abdominal circumference (cm)
97.87 (8.12)
98.2 (8.8)
95.43 (10.8)
95.82 (11.0)
Walking three-meters line (m/s)
20.17 (19.71)
20.03 (6.8)
16.95 (17.1)
20.93 (9.56)
Flexibility (cm)
28.23 (11.9)
31.8 (11.8)*
26.94 (12.3)
33.16 (9.5)
RLB (s)
32.14 (23.65)
34.29 (19.9)
24.69 (22.2)
44.97 (22.67)*
LLB (s)
28.8 (19.4)
34.06 (17.4)
31.50 (19.4)
39.57 (22.17)*
SS (times)
10.7 (2.01)
12.2 (3.17)
10.66 (2.3)
13.11 (2.8)*
Lumbar dynamometry (kg/f)
WLK: walking; CWT: circuit weight training; Acute: immediate effect of exercise; Chronic: cumulative effect of exercise; SBP: systolic
blood pressure; DBP: diastolic blood pressure; SD: standard deviation; BMI: body mass index; RLB and LLB: right and left-legged balance
(s = seconds up to a maximum of 60 s); SS: sit and stand; IADL: Lawton’s Instrumental Activities of Daily Living (0 to 9 points = dependent,
9 to 18 points = partially dependent, and 18 to 27 points = totally independent). Sample distribution measured through the Shapiro-Wilk
test; *paired Student’s t-test with significance of p ≤ 0.05; #unpaired Student’s t-test independent samples without statistical significance
between the exercise groups with 95% confidence interval.
may be more appropriate to measure muscle strength. Although
circuit training was created in 1953 in England by Morgan and
Adamson, studies with the elderly are rarely found in the literature; therefore, this prejudices the comparison with other studies.
The limiting factors of this study were the lack of a control
group, thus there was not a record of the eating habits and
diet, and no quantification of the use of salt or the frequency
and timing of continuous use of medication, not applying
maximum overload tests for specific muscle groups and no
individualized programs.
6
CONCLUSION
These two ways of intervention contributed to reductions
of glycaemia levels and probably to the improved metabolic
glucose uptake. This proposed rehabilitation is characterized
as of low cost if compared to traditional health clubs and
can be perfectly adapted to elderly community centers.
Although there was good adherence, in more than 12
weeks of sessions, progression of load and association
with changes in lifestyle are necessary to obtain significant
responses from PE.
Geriatr Gerontol Aging
Rodrigues RAS, Voltarelli FA, Carvalho CMMM, Schauffert G, Fett WCR, Fett CA
CONFLICT OF INTERESTS
ACKNOWLEDGMENTS
Th e authors report no confl ict of interests.
The authors are thankful to the elderly volunteers of this
research center’s day and to the Brazilian National Counsel
of Technological and Scientific Development (CNPq).
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