eTable. Characteristics of the Sample (n = 2016)
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Gibson CJ, Huang AJ, McCaw B, Subak LL, Thom DH, Van Den Eeden SK. Associations of Intimate Partner Violence, Sexual Assault, and Posttraumatic Stress Disorder With Menopause Symptoms Among Midlife and Older Women. JAMA Intern Med. 2019;179(1):80–87. doi:10.1001/jamainternmed.2018.5233
How common are intimate partner violence, sexual assault, and posttraumatic stress among midlife and older women, and are these exposures associated with women’s experience of menopause?
In this cross-sectional analysis of a cohort of midlife and older women, intimate partner violence, sexual assault, and symptoms of posttraumatic stress disorder were common. Emotional intimate partner violence and posttraumatic stress were associated with sleep-related, vasomotor, and vaginal symptoms; physical intimate partner violence was associated with night sweats; and sexual assault was associated with vaginal symptoms.
Intimate partner violence, sexual assault, and symptoms of posttraumatic stress disorder may be associated with the development and experience of menopause symptoms.
Little is known about the prevalence of traumatic exposures among midlife and older women and the association of these traumatic exposures with health issues.
To examine the associations of intimate partner violence (IPV), sexual assault, and posttraumatic stress with menopause symptoms among midlife and older women.
Design, Setting, and Participants
A cross-sectional analysis of data from a multiethnic cohort of 2016 women 40 to 80 years of age in the Kaiser Permanente Northern California health care system was conducted from November 15, 2008, to March 30, 2012. Statistical analysis was conducted from June 8, 2016, to September 6, 2017.
Lifetime physical or emotional IPV, sexual assault, and current symptoms of posttraumatic stress disorder, assessed with standardized questionnaires.
Main Outcomes and Measures
Difficulty sleeping, vasomotor symptoms, and vaginal symptoms, assessed with standardized questionnaires.
Among the 2016 women enrolled, the mean (SD) age was 60.5 (9.5) years, and 792 of 2011 with race/ethnicity data (39.4)% were non-Latina white (403 [20.0%] Latina, 429 [21.3%] black, and 387 [19.2%] Asian). Lifetime emotional IPV was reported by 423 women (21.0%), lifetime physical IPV was reported by 316 women (15.7%), sexual assault was reported by 382 women (18.9%), and 450 of 2000 women (22.5%) had current clinically significant symptoms of posttraumatic stress disorder. In multivariable analyses adjusted for age, race/ethnicity, educational level, body mass index, menopause status, hormone therapy, and parity, symptoms of posttraumatic stress disorder were associated with difficulty sleeping (odds ratio [OR], 3.02; 95% CI, 2.22-4.09), vasomotor symptoms (hot flashes: OR, 1.69; 95% CI, 1.34-2.12; night sweats: OR, 1.72; 95% CI, 1.37-2.15), and vaginal symptoms (vaginal dryness: OR, 1.73; 95% CI, 1.37-2.18; vaginal irritation: OR, 2.20; 95% CI, 1.66-2.93; pain with intercourse: OR, 2.16; 95% CI, 1.57-2.98). Emotional IPV was associated with difficulty sleeping (OR, 1.36; 95% CI, 1.09-1.71), night sweats (OR, 1.50; 95% CI, 1.19-1.89), and pain with intercourse (OR, 1.60; 95% CI, 1.14-2.25). Physical IPV was associated with night sweats (OR, 1.33; 95% CI, 1.03-1.72). Sexual assault was associated with vaginal symptoms (vaginal dryness: OR, 1.41; 95% CI, 1.10-1.82; vaginal irritation: OR, 1.42; 95% CI, 1.04-1.95; pain with intercourse: OR, 1.44; 95% CI, 1.00-2.06).
Conclusions and Relevance
Lifetime history of IPV or sexual assault and current clinically significant symptoms of posttraumatic stress disorder are common and are associated with menopause symptoms. These findings highlight the need for greater recognition of these exposures by clinicians caring for midlife and older women.
Violence against women is a pervasive public health issue. An estimated 25% of women will experience intimate partner violence (IPV) or sexual assault in their lifetime,1,2 and 1 in 10 women will develop posttraumatic stress disorder (PTSD) after these or other traumatic exposures.3 A growing body of evidence suggests that IPV, sexual assault, and PTSD have long-term effects on health and functioning.4,5 Over time, these exposures may compound the risks for the development of aging-related health conditions. However, most research in this area has focused on reproductive-age women,1,5 and relatively little is known about the prevalence of these experiences and their associations with health conditions among midlife and older women.1,6,7
For many midlife and older women, general health and daily functioning are affected by common, disruptive symptoms related to menopause and aging. These symptoms, including difficulty sleeping, vasomotor symptoms, and vaginal symptoms, are associated with both age-related changes and psychosocial stressors through biological and behavioral pathways.8 Although trauma and symptoms of PTSD have been linked to related somatic symptoms among reproductive-aged women, the role of these exposures in the development and exacerbation of common symptoms throughout the menopause transition is unclear.9
We examined the prevalence of IPV, sexual assault, and symptoms of PTSD in a large sample of community-dwelling midlife and older women, and evaluated the associations between these exposures and common menopause symptoms. We hypothesized that even after accounting for known demographic and clinical risk factors, IPV, sexual assault, and symptoms of PTSD would be associated with an increased risk for menopause symptoms.
This research was conducted within the Reproductive Risks of Incontinence Study at Kaiser, an observational study of risk factors for urinary tract dysfunction in community-dwelling midlife and older women. Details about the Reproductive Risks of Incontinence Study at Kaiser have been previously reported.10 In brief, participants were female enrollees in Kaiser Permanente Northern California (KPNC), an integrated health care system serving approximately 30% of the northern California population. To be eligible, women were 40 years of age or older, enrolled in KPNC since before they were 21 years, and had at least half of any childbirth events at a KPNC facility. To ensure robust participation by women with type 2 diabetes, approximately 20% of all participants were purposefully recruited from the KPNC Diabetes Registry, a database of KPNC enrollees with type 1 or 2 diabetes updated annually through active surveillance of pharmacy, laboratory, and medical records.11 All participants were randomly sampled from within age and race/ethnicity strata to provide adequate representation from women across age cohorts and racial/ethnic backgrounds. Symptoms of diabetes and/or urinary tract dysfunction were not required for participation. All procedures were approved by the institutional review boards of the University of California, San Francisco and Kaiser Permanente Division of Research. Written informed consent was obtained at the time of data collection.
The Reproductive Risks of Incontinence Study at Kaiser cohort was initially interviewed between 1999 and 2003, with 2 waves of follow-up data collection in the subsequent 10 years. Of the 4819 women initially contacted, 3438 (71.3%) were eligible, 2468 (71.8%) consented to participate, and 2016 (81.7%) completed a study visit. All data were collected through clinic- or home-based study visits. The present study draws from the third wave of data collection (November 15, 2008-March 30, 2012), which included a detailed assessment of trauma and symptoms of PTSD.
All the data on exposures and outcomes were drawn from self-administered or interviewer-administered questionnaires. Lifetime IPV and sexual assault were assessed using standardized, self-administered structured-item questionnaire measures adapted from past epidemiologic research in similar populations12 (Table 1). Positive responses were additionally probed for IPV in the previous 12 months and age at last occurrence of sexual assault. Symptoms of PTSD were assessed with the self-administered PTSD Checklist for DSM-IV, Civilian Version, previously validated to assess symptoms of PTSD within the last month related to traumatic exposures.13 To avoid confounding, a summed score excluding responses to 2 sleep-related items was used in analyses relating sleep and symptoms of PTSD.14-16 The established clinical cutoff score of 30 or more for probable PTSD in primary care populations17 was used to categorize the presence or absence of clinically significant symptoms of PTSD for all analyses.
A broad range of menopause symptoms were assessed using interviewer-administered structured-item questionnaires.15 For this analysis, we prioritized 3 types of symptoms associated with the menopause transition18: difficulty sleeping, vasomotor symptoms, and vaginal symptoms. Participants were asked, “Have you experienced the following symptoms in the past month?” Participants then responded “yes” or “no” to each symptom listed, including difficulty sleeping, hot flashes, night sweats, vaginal dryness, vaginal irritation, and pain with intercourse (if they were sexually active).
Sociodemographic characteristics were assessed with self-administered questionnaires. These characteristics included self-identified race/ethnicity, educational level, and parity. Menopause status was defined by self-reported menstrual bleeding patterns, assessed by interviewer-administered questionnaire. Women were categorized as postmenopausal if they had no menstrual cycle in the previous 12 months, whether owing to natural cessation or hysterectomy and/or oophorectomy. Use of hormone therapy within 2 years before and/or after the study visit, including systemic and local vaginal formulations, was categorized by expert review by one of us (A.J.H.). Hormone therapy was abstracted from medical records for all participants who filled 80% or more of their medications at a KPNC pharmacy, and self-reported by the remainder of the sample. Body mass index, calculated as weight in kilograms divided by height in meters squared, was measured by trained staff during study visits. Symptoms of depression and anxiety in the past week were self-reported with the Hospital Anxiety and Depression Scale,19 with the established subscale cutoff score of 8 used to categorize clinically significant symptoms.20 Chronic health conditions, including cardiovascular disease and diabetes, were self-reported based on queries about whether participants had ever been told by their medical professionals that they had any of a list of common conditions. Smoking status and weekly alcohol use were self-reported in response to queries about health behaviors.
Statistical analysis was conducted from June 8, 2016, to September 6, 2017. Descriptive statistics, including frequencies and percentages for categorical data and mean values and SDs for continuous data, were used to summarize key variables, covariates, and additional variables not included in final models. Differences in the prevalence of key exposures and outcomes by race/ethnicity were also examined and compared with χ2 analyses.
In separate multivariable logistic regression analyses, emotional IPV, physical IPV, sexual assault, and symptoms of PTSD were modeled as factors associated with difficulty sleeping, vasomotor symptoms, and vaginal symptoms, adjusted for age, menopause status, race/ethnicity, body mass index, educational level, use of hormone therapy, and parity. All covariates were selected a priori owing to known associations with menopause symptoms.21-23 In exploratory analyses, any significant associations between IPV or sexual assault exposures and menopause symptoms were assessed in equivalent models with symptoms of PTSD included as an additional covariate. All analyses were conducted using STATA, version 14 (StataCorp LP). Reported P values are 2-sided, and P < .05 was considered statistically significant.
In this multiethnic sample (792 [39.4%] non-Latina white, 429 [21.3%] black, 403 [20.0%] Latina or Hispanic, and 387 [19.2%] Asian), women were largely postmenopausal (1643 of 2002 [82.1%]; mean [SD] age, 60.5 [9.5] years), overweight or obese (1489 [73.9%]; mean [SD] body mass index, 30.2 [7.4]), and well educated (1638 of 2010 [81.5%] with some college or more) (Table 2). Less than 10% had clinically significant depressive symptoms (187 of 1994 [9.4%]), and 367 of 1994 (18.4%) reported anxiety. By design, there was a robust representation by women with type 2 diabetes (534 [26.6%]), while a minority of women reported cardiovascular disease (139 of 2009 [6.9%]), being a smoker (111 of 2010 [5.5%]), or current moderate to heavy alcohol use (176 of 1516 [11.6%]). Baseline characteristics by each exposure are detailed in the eTable in the Supplement.
Lifetime emotional IPV was reported by 423 women (21.0%), lifetime physical IPV was reported by 316 women (15.7%), and 256 of 1790 women (14.3%) reported both emotional and physical IPV (Table 3).13 Intimate partner violence occurring within the past 12 months was reported by 64 women (3.2%; 57 of 64 women [89.1%] reported emotional IPV in the past 12 months) and was not examined in subsequent analyses owing to insufficient power. A total of 382 women (19.0%) reported sexual assault, with most (278 of 382 [72.8%]) occurring when participants were younger than 25 years. Overall, 450 of 2000 women (22.5%) met criteria for current clinically significant symptoms of PTSD. Significant variation in the rates of lifetime IPV and sexual assault were seen between racial/ethnic groups, with reported rates of all exposures lowest among Asian women. In contrast, observed rates of current symptoms of PTSD were equivalent across racial/ethnic groups.
Menopause symptoms were common, with 1148 women (57.1%) reporting difficulty sleeping, 802 (39.9%) reporting hot flashes, 692 (34.4%) reporting night sweats, 633 (31.5%) reporting vaginal dryness, 260 (12.9%) reporting vaginal irritation, and with 257 of 1457 sexually active women (17.6%) reporting pain with intercourse (Table 3).13 Significant variation in rates of some menopause symptoms were seen between racial/ethnic groups, with vasomotor symptoms most common among black women.
In multivariable adjusted analyses, women who reported lifetime emotional IPV were more likely to report difficulty sleeping (odds ratio [OR], 1.36; 95% CI, 1.09-1.71), night sweats (OR, 1.50; 95% CI, 1.19-1.89), and pain with intercourse (OR, 1.60; 95% CI, 1.14-2.25) (Table 4).13 Women who reported lifetime physical IPV were more likely to report night sweats (OR, 1.33; 95% CI, 1.03-1.72), while those reporting lifetime sexual assault were more likely to report vaginal dryness (OR, 1.41; 95% CI, 1.10-1.82), vaginal irritation (OR, 1.42; 95% CI, 1.04-1.95), and pain with intercourse (OR, 1.44; 95% CI, 1.00-2.06). Symptoms of PTSD were associated with all menopause symptoms, including difficulty sleeping (OR, 3.02; 95% CI, 2.22-4.09), hot flashes (OR, 1.69; 95% CI, 1.34-2.12), night sweats (OR, 1.72; 95% CI, 1.37-2.15), vaginal dryness (OR, 1.73; 95% CI, 1.37-2.18), vaginal irritation (OR, 2.20; 95% CI, 1.66-2.93), and pain with intercourse (OR, 2.16; 95% CI, 1.57-2.98).
In exploratory analyses with symptoms of PTSD included in models with IPV and sexual assault, symptoms of PTSD remained significantly associated with all menopause symptom outcomes, while previously significant associations between IPV and sexual assault with menopause symptoms were largely attenuated. Independent associations between emotional IPV with night sweats (OR, 1.41; 95% CI, 1.11-1.79) and pain with intercourse (OR, 1.44; 95% CI, 1.02-2.05), as well as an association between sexual assault and vaginal dryness (OR, 1.33; 95% CI, 1.03-1.72), remained significant.
In this cohort of ethnically diverse midlife and older women not selected to be at high risk for traumatic exposures, 1 in 5 had experienced IPV and/or sexual assault, and almost 1 in 4 had clinically significant symptoms of PTSD. These exposures were commonly reported among women in all racial/ethnic groups. Accounting for established demographic and clinical risk factors, we found that women with a history of emotional IPV and/or current symptoms of PTSD were at increased risk for difficulty sleeping, vasomotor symptoms, and vaginal symptoms. Women with a history of physical IPV were more likely to report night sweats, while sexual assault was associated with vaginal symptoms.
These findings add to an emerging literature on the association of trauma with health conditions among women past reproductive age. Other studies have demonstrated the broad effects of emotional, physical, and sexual abuse among midlife and older women, including mood symptoms and disorders,7,24-28 sexually transmitted infections,7 urinary tract infections,7 gastrointestinal symptoms,27,29 cardiovascular risk factors,27 chronic pain,27,29 and accelerated decline in physical function.30 To our knowledge, the association between lifetime IPV or sexual assault and menopause symptoms has not been previously examined. However, evidence from the Study of Women’s Health Across the Nation suggests a similar association between childhood abuse and hot flashes,31 while smaller studies of women seeking menopause-related care suggest that IPV in the past year is associated with general menopause symptoms32 and poor sleep among women in midlife.33
Most research in this area has emphasized concerns among reproductive-aged women. Previous studies have similarly supported a pronounced association of emotional IPV with a range of related symptoms, including difficulty sleeping34 and sexual dysfunction,35 with fewer associations seen with physical IPV. Past research has also supported specific associations between sexual assault and genitourinary health, including genitourinary symptoms36,37 and chronic sexual pain38 and pelvic pain.39 These findings suggest that these associations persist in midlife and older women, despite potentially greater elapsed time since the trauma occurred, as well as age-related differences in symptom causes.
These findings add to a small but growing literature examining the association of PTSD with health conditions among women. Research in women past reproductive age has focused largely on PTSD-related cardiovascular risk40-42; the association between PTSD and menopause symptoms has not been previously assessed, to our knowledge. However, our findings are consistent with other studies linking symptoms of PTSD with a range of similar symptoms across a lifespan. Among younger female veterans, symptoms of PTSD have been associated with increased risk for genitourinary symptoms4 and chronic sexual pain38 and pelvic pain,36,37,39 in some cases mediating observed associations with sexual assault.37 Other symptoms are characteristic of both PTSD and the menopause transition, making the directionality or the cause difficult to determine. These symptoms include difficulty sleeping, the most commonly reported symptom of PTSD, and night sweats, frequently reported among both men and women with PTSD.43 In our study, symptoms of PTSD were strongly and consistently associated with all menopause symptoms assessed and, in exploratory analyses, accounted for some observed associations between IPV, sexual assault, and menopause symptoms.
A number of biological and behavioral factors may augment risk for the development or exacerbation of menopause symptoms among women who have experienced IPV, sexual assault, or symptoms of PTSD.44 Menopause symptoms are largely attributed to biological and hormonal changes related to menopause and aging, as well as health risk behaviors, cardiometabolic risk factors, and chronic health conditions that occur at a higher rate during and after the menopause transition.18 These factors all may be affected by trauma and its psychological sequelae. Alterations in the physiological response to stress may be associated with the hormonal and physiological changes of menopause and aging, affecting biological susceptibility to these symptoms. Chronic hyperarousal and hypervigilance, common in individuals who have experienced trauma and characteristic symptoms of PTSD, may affect sleep and symptom sensitivity. Health behaviors such as smoking, alcohol use, and sedentary behavior contribute to risk and poor management of sleep, vasomotor symptoms, and vaginal symptoms. Interpersonal challenges related to trauma, including conflict, avoidance, and emotional discomfort with intimacy, may contribute to the observed associations of emotional IPV, sexual assault, and symptoms of PTSD with sexual function. Menopause symptoms may also affect symptoms of PTSD, which can have a chronic and fluctuating course affected by psychosocial factors relevant to this period.45 Menopause symptoms can affect a woman’s feelings of self-efficacy,46 impair interpersonal engagement,47 and highlight stress related to life transitions,47 which also affect the experience of symptoms of PTSD.48 Sleep disturbance and disorders are also well-established risk factors for the general severity of symptoms of PTSD.49
These findings should be interpreted in light of limitations. Longitudinal trends, including elapsed time since trauma, duration or chronicity of menopause symptoms and traumatic exposures, and temporal associations between variables, cannot be determined with these cross-sectional data. Questions used to categorize IPV and sexual assault have not undergone detailed psychometric evaluation. In addition, some aspects of emotional IPV, such as controlling behavior, were not assessed. The broad assessment of these experiences limits our ability to determine the timing and severity of abuse. Menopause symptoms were not assessed with a validated instrument, and may not reflect clinical significance or meet diagnostic criteria. Pain with intercourse was assessed only among women who reported being currently sexually active, excluding one-third of the sample who may be abstinent owing to relevant but unassessed factors. It is unknown whether assessed symptoms of PTSD are associated with reported IPV and/or sexual violence among women with both exposures. In addition, we cannot determine whether participants had disclosed traumatic experiences, had previously identified diagnoses of PTSD, and/or had previously engaged in trauma-focused treatment, all of which may affect the association of these exposures with current health and functioning. Symptoms including difficulty sleeping and night sweats are common with both PTSD and menopause, making these associations difficult to interpret. For some women, hormone therapy was based on self-report and therefore subject to recall bias. When available, data on the use of hormone therapy were obtained from pharmacy records and included any use in the 2 years before and/or after the study visit. It therefore cannot be determined whether use of hormone therapy was ongoing at the time of the study visit, and whether it affected symptom reports.
Despite these limitations, this study has multiple strengths, including characterization of varied aspects of the experience of menopause symptoms, traumatic exposures, and symptoms of PTSD in a large, ethnically diverse sample of community-dwelling middle-aged and older women. These findings provide a significant contribution to the limited literature on health related to IPV, sexual assault, and symptoms of PTSD among women past reproductive age, who may be at risk for the long-reaching effects of these exposures.25
These findings have important clinical implications. First, routine assessment of traumatic exposures and symptoms of PTSD may enhance effective management of menopause. The prevalence of these exposures and their association with health conditions in a sample of relatively healthy, long-term insured midlife and older women with above-average access to care highlights the importance of these concerns for women across age and socioeconomic strata. Current screening guidelines focus on physical IPV in the past year among reproductive-aged women. Although this guideline may address acute safety concerns, our study suggests that emotional IPV may be a common and important risk factor broadly affecting the development and exacerbation of health-related symptoms. Similarly, PTSD remains an underrecognized mental health concern for women, with a broad effect on health. Although screening for depression has become common practice across health care settings, clinically significant symptoms of PTSD were twice as common as depressive symptoms in this study and were strongly associated with the potentially disruptive menopause symptoms.
The clinical management of menopause symptoms may also be enhanced by trauma-informed care, including recognition of challenges that may impair efforts to address menopause-related concerns among women affected by trauma. These challenges often include difficulty establishing trust, discomfort with disclosure and physical examinations, and reliance on unhealthy coping strategies that may exacerbate symptoms and interfere with the management of symptoms.50,51 Clinicians may be able to address these challenges and play a central role in the healing process by providing psychoeducation about the connections between trauma and health, fostering a safe and supportive treatment environment that promotes patient autonomy, and facilitating referrals for psychological and/or trauma-specific services.50 Research evaluating trauma-informed care is in its infancy,52 and attention to this issue in the context of menopause is nonexistent. These findings suggest that research on the development and evaluation of trauma-informed care to improve the management of menopause in this vulnerable population is warranted.
Lifetime IPV, sexual assault, and current symptoms of PTSD were common in this community-dwelling cohort of midlife and older women and were associated with a significantly increased risk for potentially disruptive menopause symptoms. These findings point to the need for recognition of the prevalence and importance of traumatic exposures and symptoms of PTSD by clinicians caring for midlife and older women, and for efforts to provide trauma-informed care for women across the aging spectrum.
Accepted for Publication: August 10, 2018.
Corresponding Author: Carolyn J. Gibson, PhD, MPH, San Francisco VA Medical Center, 116P, 4150 Clement St, Bldg 8, Room 207B, San Francisco, CA 94121 (email@example.com).
Published Online: November 19, 2018. doi:10.1001/jamainternmed.2018.5233
Author Contributions: Dr Gibson had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Gibson, Huang, McCaw, Subak, Van Den Eeden.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Gibson, McCaw.
Critical revision of the manuscript for important intellectual content: All authors.
Obtained funding: Gibson, Huang, Subak, Thom.
Administrative, technical, or material support: Subak, Van Den Eeden.
Supervision: Huang, Subak, Van Den Eeden.
Conflict of Interest Disclosures: Dr Huang reported receiving research grants from Pfizer Inc and Astellas through the University of California San Francisco to conduct research unrelated to this study. No other disclosures were reported.
Funding/Support: This research was supported by the resources and facilities of the San Francisco Veterans Affairs (VA) Medical Center (including the VA Advanced Fellowship Program in Women’s Health and VA Health Services Research & Delivery Career Development Award 17-018 [Dr Gibson]) and Kaiser Permanente Northern California. Funding was provided by grant P50 DK064538 from the University of California San Francisco–Kaiser Permanente Grants Program for Delivery Science, the Office of Research on Women’s Health Specialized Center of Research and grants DK53335 and 2K24DK080775-06 from the National Institute of Diabetes and Digestive and Kidney Diseases.
Role of the Funder/Sponsor: The design and conduct of the Reproductive Risks of Incontinence Study at Kaiser study, including initial data collection, was funded by the Office of Research on Women’s Health Specialized Center of Research and the National Institute of Diabetes and Digestive and Kidney Diseases. The University of California San Francisco–Kaiser Permanente Grants Program for Delivery Science approved the design and conduct of the current study, and provided funding for the management of data. The funding sources were not involved in the analysis or interpretation of data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication.
Additional Contributions: Arona Rogins, PhD, Kaiser Permanente Division of Research, assisted in the initial Reproductive Risks of Incontinence Study at Kaiser data collection, and Jun Shan, PhD, Kaiser Permanente Division of Research, assisted with data management and reconciliation. They were not directly compensated for their contributions.
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