Written evidence submitted by the International
Scientific Forum on Alcohol Research and AIM, Alcohol in Moderation
(AG 09)
INTRODUCTION
Each year our understanding of the biological, physiological,
psychological and social effects of drinking alcohol at different
doses grows. In general, national guidelines reflect the medical
findings of the j shape curve, that is, that approximately 20g
a day consumption for women and 30g consumption a day for men
is considered as "safe" or "low risk" for
most healthy adults. Therefore we believe the current UK guidelines
to be in accordance with the science base.
The science base for the health consequences of both
alcohol misuse and moderate consumption, although important should
not be the only factor considered by governments when producing
guidelines as the purpose of recommendations is to encourage adults
to drink within the responsible drinking guidelines. Hence, it
is important to continue to promote a simple public health message
that is likely to respected and regarded as realistic by consumers.
1. What evidence are Government's guidelines
on alcohol intake based on, and how regularly is the evidence
base reviewed?
1.1 AIM, Alcohol in Moderation was one of many organisations
that submitted a paper in 1995 to the sensible drinking guidelines
review, drawing on evidence from eminent epidemiologists such
as Sir Richard Doll, Professor Eric Rimm (USDA committee) and
Professor R Curtis Ellison as well as cardiologists such as Professor
Art Klatsky. In particular, the evidence base in the early 1990's
showed the importance of a daily "little and often"
guideline versus "saving up" units and drinking on one
or two nights a week.
1.2 We are able to have "low risk" guidelines,
rather than a message of "don't drink" due to the medical
evidence base, which began with the publication by Professor Klatsky
in 1974 of one of the first studies to suggest an inverse association
between moderate alcohol consumption and coronary heart disease,
This was followed in 1979 with St Leger in The Lancet finding
that wine appeared to be protective against heart disease, independent
of other risk factors. Since then, many hundreds of studies from
25 countries have confirmed and strengthened the association,
with the protective effect, or what has become known as the J
shaped curve for moderate alcohol consumption, applying predominantly
to post menopausal women and men over 40.
1.3 The j shaped curve shows that light and moderate
drinkers of any form of alcohol live longer than those who abstain
or drink heavily. The relative risk of mortality is lowest among
moderate consumers (at the lowest point of the J), greater among
abstainers (on the left-hand side of the J), and much greater
still among heavy drinkers (on the right-hand side of the J).
In addition to longevity in general, the J-shaped relationship
also exists for cardiovascular deaths, specifically for coronary
heart disease and ischemic stroke.
1.4 Many factors influence the definition of safe
alcohol consumption and include age, gender, body mass index,
ethnicity, family history, genetic differences, mental and physical
health, and concomitant medications. Consequently, it has not
been possible to determine the exact inflection point in dose
where a potentially beneficial, or harmless dose changes to a
potentially harmful one, hence definitions of a drink and responsible
drinking guidelines vary from country to country and governments
usually use simple messages and recommendations that apply to
the majority general population.
1.5 Moderate drinking is generally medically defined,
however, as approximately 20g a day (one or two standard drinks)
for women and 30g a day for men. Further, epidemiological studies
have assessed the importance of drinking patterns including frequency
and quantity. "Saving up" units for drinking on one
or two occasions a week is not considered moderate drinking.
HOW CAN
MODERATE AND
REGULAR DOSES
OF ALCOHOL
BE PROTECTIVE?
1.6 Evidence from these studies suggests that beneficial
changes in High Density Lipoprotein cholesterol levels, clotting
factors, insulin sensitivity, and markers of inflammation provide
biological plausibility to the association. Coronary heart disease
(CHD) is the leading cause of death throughout the developed world,
accounting for 25-50% of all deaths. Studies consistently show
that regularly consuming moderate amounts of alcohol reduces mortality
from CHD and ischemic stroke by 25 -30%, mainly in men aged over
40 years and in postmenopausal women, when the risk factors for
CHD and stroke significantly increase.
1.7 It is thought that alcohol itself accounts for
75% of the cardio-protective effects of alcoholic beverages. It
favourably alters the balance of fats or lipids in the blood,
by stimulating the liver to produce the "good" high-density
lipoprotein cholesterol (HDL). HDL removes the "bad"
low-density lipoprotein cholesterol (LDL) from arteries and veins
for disposal via the bile, which is referred to as reverse cholesterol
transport.Alcohol decreases blood clotting and/or the "stickiness"
of blood platelets, which if untreated could form a clot to block
blood flow in an artery to cause a heart attack or stroke. The
message is little and often as the blood thinning effect of alcohol
lasts for approximately 24 hours and one drink confers the benefit.
1.8 Drinking alcohol is not recommended if suffering
from uncontrolled, high blood pressure. If someone has an existing
heart condition, alcohol can generally be drunk in moderation,
but only if alcohol use does not affect the medication, a doctor's
advice should be sought. Binge drinking is seen to significantly
increase systolic blood pressure, which increases the risk of
a heart attack or stroke.
1.9 The many epidemiological studies that have shown
an inverse relation between alcohol and cardiovascular disease
have come from a great variety of nations and cultures. Despite
great diversity in the populations, study size, diet and lifestyle
factors and length of follow-up the consistency and similarity
of outcomes provide further support to the robustness of the findings.
Inverse associations have been documented in France, Japan, Denmark,
Germany, Finland, Korea, Great Britain Australia, China, Italy,
Puerto Rico, the Netherlands, Sweden, Yugoslavia and the US (see
references).
1.10 More recent studies of alcohol and CHD have
focused on subgroups defined by age or health status. Although
alcohol in moderation will likely provide greater benefit for
older populations where rates of CHD are highest, the etiology
of CHD is such that moderate consumption in middle age also is
beneficial. Several important risk factors for CHD, such as obesity
and the prevalence of type 2 diabetes, both of which have been
increasing in younger adults around the world, are consistently
reported to be inversely associated with moderate alcohol consumption.
MOST RECENT
EVIDENCE
1.11 An important meta-analysis of 4235 studies on
the association of alcohol consumption with selected cardiovascular
disease outcomes was published in the BMJ in 2011: This meta-analysis
provides a summary of current knowledge regarding alcohol associations
with six meaningful clinical end points—cardiovascular disease
mortality, coronary heart disease incidence and mortality, stroke
incidence and mortality, and all cause mortality. Reflecting previous
meta-analysis by Maclure in 1993 and by Corrao et al in 2000,
the results demonstrate risk reductions for alcohol drinkers relative
to non-drinkers of 25% for cardiovascular disease mortality, 29%
for incident coronary heart disease, 25% for CHD mortality and
13 % for all cause mortality. The lowest risk of CHD mortality
occurred with 1-2 drinks (15-30 grams of alcohol) per day is also
in line with previous knowledge. (Paul E Ronksley, Barbara J Turner,
Kenneth J Mukamal et al BMJ 2011;342:d671 doi:10.1136/bmj.d671
Effect of alcohol consumption on biological markers associated
with risk of coronary heart disease: systematic review and meta-analysis
of interventional studies Susan E Brien, Paul E Ronksley, Barbara
J Turner, Kenneth J Mukamal, William A Ghali Cite this as: BMJ
2011;342:d636 doi:10.1136/bmj.d636).
1.12 Another recent paper set out to determine the
extent to which potential "errors" in many early epidemiologic
studies led to erroneous conclusions about an inverse association
between moderate drinking and coronary heart disease (CHD). Based
on prospective data for more than 124,000 persons Fuller concludes
that the so-called "errors" have not led to erroneous
results, and that there is a strong protective effect of moderate
drinking on CHD and all-cause mortality. (Fuller TD. Moderate
alcohol consumption and the risk of mortality. Demography 2011.
DOI 10.1007/s13524-011-0035-2).
PATTERN OF
DRINKING
1.13 Research is increasingly showing the importance
of drinking at meal times, this is known as the "post prandial
state". This not only decreases the effect of alcohol (drinking
on an empty stomach), but helps us counter damaging free radicals.
Rich foods increase the state of "oxidative stress"
in the body. Research shows that drinking above 30g a day outside
of meal times or abstinence increases the risk of blood pressure
and all cause mortality significantly.
1.14 Research also emphasizes regular moderate versus
episodic or binge drinking . An important prospective study shows
that regular moderate drinking is associated with lower risk of
MI, but episodic or binge drinking increases the risk. Lifetime
abstinence has a similar adverse relation to CHD. Reference: Ruidavets
J-B, Ducimetièere P et al Patterns of alcohol consumption
and ischaemic heart disease in culturally divergent countries:
the Prospective Epidemiological Study of Myocardial Infarction
(PRIME). BMJ 2010;341:c6077 doi:10.1136/bmj.c6077.
CANCER RISK
1.15 There is no doubt that the prolonged excessive
consumption of alcohol, especially when combined with smoking,
leads to an increased incidence of many cancers (mouth, throat,
larynx, oesophagus, breast and liver). A growing body of epidemiological
studies show evidence for a positive association, even at moderate
levels for breast cancer risk,(estimated lifetime increased risk
of 6% per daily drink). Lifestyle factors such as diet and adequate
folate intake may weaken the positive association, but this is
an area still under study. The risk of breast cancer from alcohol
consumption is additive with other risks such as: lifestyle; family
history; medical history; nulliparity; endogenous/exogenous hormones
(such as hormone replacement therapy); body mass index; and environmental
exposure to carcinogens.
1.16 Cancer risk should not be considered in isolation
from the risk of other factors for mortality, as regards responsible
drinking guidelines. As regards all cause mortality, the current
daily guidelines reflect the scientific findings well in recommending
safe or low risk guidelines for alcohol consumption for healthy
adults.
POTENTIAL CONFOUNDERS
1.17 It has been suggested that the inverse association
between alcohol and all cause mortality may not be causal but
because moderate drinkers may be better off, more likely to eat
better, exercise more, and live a healthier life. Most studies
from the last decade account for potential con-founders of the
effect of moderate drinking - such as education, occupation, social
status, physical activity, diet, and changes in alcohol consumption
during lifetime. Although most prospective studies of alcohol
and cardiovascular risk are observational, trials have been conducted
to study changes in markers of CHD such as HDL cholesterol, triglycerides,
glycemic control, and clotting factors and support the conclusions
of the observational studies.
1.18 Klatsky and Udaltsova (2007) reworked previously
published data to address the purported confounding and potential
over-estimation of a health benefit from moderate alcohol consumption
claimed by Fillmore et al (2006, 2007), and showed a shallower
but still significant J-shaped relationship between alcohol consumption
and all-cause mortality risk. The data was of 21,535 deaths and
follow-up included 2,618,523 person-years of observation (average
20.6 years). Their re-analysis reconfirmed the relationship previously
published with an increased risk for individuals consuming more
than three (14 g) drinks per day and a reduced risk at three or
less drinks per day, almost always due to a reduced risk of death
from cardiovascular disease. Former consumers were observed to
be at increased risk of death from non-cardiovascular disease
and occasional consumers were observed to have a risk similar
to lifelong abstainers.
1.19 Another study by Mukamal et al (2006)
on older adults separated lifetime abstainers from former drinkers,
and occasional drinkers from regular light drinkers It demonstrated
reductions in the risk of a variety of cardiovascular outcomes
from moderate consumption. Another study on older people by Tolvanen
(2005) separating ex-drinkers were from lifetime abstainers, total
mortality was highest in the ex-drinkers and labstainers, and
30?40%
lower in current consumers.
OLDER POPULATIONS
1.20 There have been suggestions that the elderly
should reduce their alcohol consumption to below daily drinking
guidelines. This is based on the fact that they have less body
water than younger adults. However, moderate, regular consumption,
within the guidelines helps protect against cardiovascular disease,
cognitive decline and all cause mortality, especially among post
menopausal women and men over 40, hence the US dietary guidelines
2010 cite:
In most Western countries where chronic diseases
such as CHD, cancer, stroke and diabetes are the primary causes
of death, results from large epidemiological studies consistently
show that alcohol has a favorable association with total mortality
especially among middle age and older men and women ….
1.21 This message has been further strengthened this
month by the findings of the nurses health study( Alcohol Consumption
at Midlife and Successful Ageing in Women: A Prospective Cohort
Analysis in the Nurses' Health Study) following 14,000 older women
for 16 years. Those who consumed between 15g and 30g of alcohol
regularly had a 28% better chance of "successful ageing versus
abstainers or light occasional drinkers (http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001090).
1.22 Another recent paper finds that after adjusting
for former problem drinking status, health and social-behavioural
factors, moderate drinking was associated with considerably lower
risk of all-cause mortality. In comparison with "moderate
drinkers" (subjects reporting up to 3 drinks/day), abstainers
had 51 % higher mortality risk and heavy drinkers had 45% higher
risk. (Holahan CJ et al. Late-Life Alcohol Consumption and
20-Year Mortality. Alcoholism: Clinical and Experimental Research
2010;34).
THE LIVER
1.23 There is no question that heavy alcohol consumption
is a key factor in the development of Laennec's cirrhosis, and
that almost all studies show that women may be at greater risk
than men for a specified level of intake. The key question for
public health officials is whether or not there is a threshold
level of drinking associated with increased risk of cirrhosis.
A recent meta-analysis supports the theory that there
is a threshold of drinking above which the risk is increased.
The study reported that for morbidity from cirrhosis, both men
and women consuming up to one drink per day had a lower risk than
that of lifetime abstainers. Women had a significantly increased
risk above 24 grams/day and men above 36 grams/day. This suggests
that there may a threshold effect of alcohol on the risk of cirrhosis
in line with current guidelines. (Rehm J, Alcohol as a risk factor
for liver cirrhosis: A systematic review and meta-analysis. Drug
and Alcohol Review 2010,29,437-445. DOI: 10.1111/j.1465-3362.2009.00153.x).
DIFFERENCES IN
GUIDELINES FOR
MEN AND
WOMEN
1.24 There are physiological gender differences in
body size and the distribution of fat and water, as well as in
alcohol metabolism that determine that for a given amount of alcohol,
the resultant BAC is greater in women than in men. The maximal
BAC may be approximately 10-16% greater in women compared to men.
In addition it should also be stated that women's organs and tissues
are more susceptible to the toxic effects of alcohol and its metabolite
such that harmful effects of regular heavy drinking are observed
earlier in women. Hence the current lower guidelines for women
are correct and balanced.
PREGNANCY
1.25 Both NICE and The Royal College of Obstetricians
and Gynaecologists have reviewed the extensive evidence base and
the current guidelines are in line with their findings.
PARAMETERS OF
MISUSE
1.26 There are significant economic,
medical and social consequences from irresponsible or high risk
alcohol consumption. Heavy or hazardous drinking ( more than twice
the moderation guidelines), inappropriate drinking ( drinking
to drunkenness), and binge drinking ( more than five drinks in
quick succession) have no health benefits and are associated with
both acute and chronic harms to health, both short and long term.
Drinking at all in some circumstances
is hazardous, such as when pregnant, on certain medications, when
driving, suffering from some illnesses, working with machinery
or at heights.
2. Could the evidence base and sources of
scientific advice to Government on alcohol be improved?
2.1 You will find forwarded separately examples of
how the Canadian and US Government's http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/DGAC/DGACpressrelease10-24-08.pdf
conduct their responsible drinking guideline reviews, with an
experienced panel of predominantly MEDICAL specialists and epidemiologists
and nutrition lists reviewing the evidence collated reporting
to a BALANCED panel of expertise.
2.2 The US guidelines are reviewed every five years.
Australia and Canada more sporadically. You will find a recent
review of common themes in country guidelines under separate cover.
2.3 It is very important that the evidence base is
not based on a few individual papers but on a comprehensive database
of studies and meta- analyses from different disciplines, please
see the bibliography for the US and Canadian reviews.
2.4 There is a feeling among the 40 scientists and
medical doctors that contribute comment to The International Scientific
Forum on Alcohol Research http://www.bu.edu/alcohol-forum/members/
(unpaid) and AIM http://www.aim-digest.com/digest/index.htm who
are directly involved in alcohol and health research that there
is an unhealthy reliance on non medically qualified public health
statisticians and use of mathematical modelling - such as the
use of alcohol attributable fractions for example rather than
analysing the hard science.
2.5 Evidence needs to take account of cardiology,
hepatology, oncology, all cause mortality, epidemiology, pattern
of drinking and put alcohol in context with other lifestyle factors
such as BMI, smoking, exercise and diet. NICE may be the best
body to bring together such a panel.
4. How do the UK Government's guidelines compare
to those provided in other countries?
4.1 The UK definition of a unit is the smallest at
8g. Unit definition varies from 10g ( Australia, France, Austria,
Ireland, The Netherlands, New Zealand) 12g (Denmark, Italy), 13.6-14g
(Canada and US) and 19.75 (Japan).
4.2 In spite of this, daily drinking guidelines where
they exist , are broadly in line—suggesting an average intake
of 20g a day for women and 30g for men.
4.3 The lowest guidelines for women are Poland at
10g and 14g a day from the US, with an average of 20g (WHO guidelines,
France, Australia, New Zealand, Sweden, Switzerland). Some of
the highest are from Canada (27.2g). the UK sits comfortably in
the evidence zone of suggesting 16-24g as a daily guide.
4.4 The lowest guidelines for men are 20g in Poland,
Sweden and Australia (up to 40g on occasions), rising to 28g in
the US, 30g in France, New Zealand and WHO, and 40g in Spain,
hence the UK guide of 24-32g is in balance.
4.5 For the many countries where there are no official
Government guidelines, such as Belgium, China, Germany, Hungary,
India or Russia, it is recommended that the WHO low risk responsible
drinking guidelines are followed. Which are:
(2) Women should not drink more than two drinks
(10g) a day on average.
(3) For men, not more than three drinks (10g)
a day on average.
(4) Try not to exceed four drinks on any one
occasion:
(0) Don't drink alcohol in some situations, such
as when driving, if pregnant or in certain work situations and
abstain from drinking at least once a week.
Men or women who consistently drink more than these
recommended levels may increase risks to their health.
INCREASING MOVES
TO STATING
A MAXIMUM
NUMBER OF
DRINKS A
DAY
4.6 Reflecting an acknowledgement that people celebrate
and party, several guidelines now have an "upper limit":
— US
guidelines: No more than three drinks in any single day for women
(42g) and for men no more than four drinks (56g) in any single
day for men.
— WHO
- no more than 4 drinks on one occasion (40g).
— Australia's
2008 guidelines: up to 40 g of ethanol on occasional days for
men and women.
4.7 Protection for older populations
Canadian guidelines: "men
and women consuming up to 14 and 9 standard drinks (13.6g) per
week respectively, have a lower risk of early death than abstainers."
UK guidance: "The
health benefits are more evident from regular daily drinking."
Specifically, men over age 40 and postmenopausal women are emphasized
as recipients of a "significant health benefit in terms of
reduced coronary heart disease mortality and morbidity."
Middle aged or elderly non-drinkers or infrequent drinkers and
especially those at risk for heart disease "may wish to consider
the possibility that light drinking may be of benefit to their
overall health and life expectancy."
US revised guidelines 2010:
"In most Western countries where
chronic diseases such as CHD, cancer, stroke and diabetes are
the primary causes of death, results from large epidemiological
studies consistently show that alcohol has a favourable association
with total mortality especially among middle age and older men
and women".
4.8 Balance between harms and benefits
These are reflected well in the US guideline conclusions:
"The hazards of heavy alcohol (ethanol) intake
have been known for centuries. Heavy drinking increases the risk
of liver cirrhosis, hypertension, cancers of the upper gastrointestinal
tract, injury, and violence. An average daily intake of one to
two alcoholic beverages is associated with the lowest all-cause
mortality and a low risk of diabetes and CHD among middle-aged
and older adults. Despite this overall benefit of moderate alcohol
consumption, the evidence for a positive association between alcohol
consumption and risk of unintentional injuries and breast and
colon cancer should be taken into consideration. The DGAC recommends
that if alcohol is consumed, it should be consumed in moderation,
and only by adults. "Reference: www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/Chapter3.pdf".
So, to conclude, The International Scientific Forum
on Alcohol Research and the social Scientific and Medical Council
of Alcohol in Moderation believe the current guidelines reflect
the current scientific evidence base regarding alcohol and health
and definitions of safe or low risk drinking well. It may be wise,
as is the case with the USDA guidelines, to review the evidence
base every 5 years to ensure that emerging research is accounted
for.
FORUM DIRECTORS
R Curtis Ellison, MD,
Section of Preventive Medicine/Epidemiology, Boston University
School of Medicine, Boston, MA, USA (Co-Director)
Helena Conibear, Alcohol
in Moderation, Bath, UK (Co-Director)
FORUM MEMBERS
Alan Crozier, PhD, Plant
Biochemistry and Human Nutrition, University of Glasgow, Scotland,
UK
Alun Evans, MD, Centre
for Public Health, The Queen's University of Belfast, Belfast,
UK
David Vauzour, PhD, Senior
Research Associate, Department of Nutrition, Norwich Medical School,
University of East Anglia, Norwich, UK
Oliver James, MD, Head
of Medicine, University of Newcastle, UK
Jeremy P E Spencer, PhD,
Reader in Biochemistry, The University of Reading, UK
Alberto Bertelli, MD,
PhD, Institute of Human Anatomy, University of Milan, Italy
Dee Blackhurst, PhD, Lipid
Laboratory, University of Cape Town, Cape Town, South Africa
Giorgio Calabrese, MD,
Docente di Dietetica e Nutrizione, Umana Università Cattolica
del S. Cuore, Piacenza, Italy
Maria Isabel Covas, DPharm,
PhD, Cardiovascular Risk and Nutrition Research Group, Institut
Municipal d´Investigació Mèdica, Barcelona,
Spain
Giovanni de Gaetano, MD,
PhD, Research Laboratories, Catholic University, Campobasso, Italy
Luc Djoussé, MD,
DSc, Dept. of Medicine, Division of Aging, Brigham & Women's
Hospital and Harvard Medical School, Boston, MA, USA
Harvey Finkel, MD, Hematology/Oncology,
Boston University Medical Center, Boston, MA, USA
Tedd Goldfinger, DO, FACC,
Desert Cardiology of Tucson Heart Center, University of Arizona
School of Medicine, Tucson, AZ, USA
Lynn Gretkowski, MD, Obstetrics/Gynecology,
Mountainview, CA, Stanford University, Stanford, CA, USA
Dwight Heath, PhD, Dept.
of Anthropology, Brown University, Providence, RI, USA
Ulrich Keil, MD, Institute
of Epidemiology & Social Medicine, University of Muenster,
Germany
Arthur Klatsky, MD, Dept.
of Cardiology, Kaiser Permanente Medical Center, Oakland, CA,
USA
Maritha J Kotze, PhD,
Human Genetics, Dept of Pathology, University of Stellenbosch,
Tygerberg, South Africa.
Dominique Lanzmann-Petithory,MD,
PhD, Nutrition/Cardiology, Praticien Hospitalier Hôpital
Emile Roux, Paris, France
Federico Leighton, MD,
Laboratorio de Nutricion Molecular, Facultad de Ciencias Biologicas,
Universidad Catolica de Chile, Santiago, Chile
Ross McCormick, PhD, MSc,
MBChB, Associate Dean, Faculty of Medical and Health Sciences,
The University of Auckland, Auckland, New Zealand
Francesco Orlandi, MD,
Dept. of Gastroenterology, Università degli Studi di Ancona.
Italy
Lynda H Powell, MEd, PhD,
Chair, Dept. of Preventive Medicine, Rush University Medical School,
Chicago, IL, USA
Ian Puddey, MD, Dean,
Faculty of Medicine, Dentistry & Health Sciences, University
of Western Australia, Nedlands, Australia
Erik Skovenborg, MD, specialized
in family medicine, member of the Scandinavian Medical Alcohol
Board, Aarhus, Denmark
Jan Snel, PhD, Social
and Behavioral Sciences, University of Amsterdam, Amsterdam, Holland
Arne Svilaas, MD, PhD,
general practice and lipidology, Oslo University Hospital, Oslo,
Norway
Pierre-Louis Teissedre,
PhD, Faculty of Oenology-ISVV, University Victor Segalen Bordeaux
2, Bordeaux, France
Gordon Troup, MSc, DSc,
School of Physics, Monash University, Victoria, Australia
Fulvio Ursini, MD, Dept.
of Biological Chemistry, University of Padova, Padova, Italy
David Van Velden, MD,
Dept. of Pathology, Stellenbosch University, Stellenbosch, South
Africa
Andrew L Waterhouse, PhD,
Marvin Sands Professor, Department of Viticulture and Enology,
University of California, Davis.
Yuqing Zhang, MD, DSc,
Clinical Epidemiology, Boston University School of Medicine, Boston,
MA, USA
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