Brain not working. Who should I take it to?
November 3, 2013 2:50 PM   Subscribe

Fatigue, low mood, and cognitive sluggishness, none of which is new but which has been more acute than usual the last few weeks. YANMD, but what kind of professional should I see and what tests should I get?

Everything I'm describing below is stuff I've had on and off for most of my life, but in the last month or so it's been worse than usual. I have a dissertation to finish, piles of grading to do on a regular basis, and a job to find, so this really isn't helping. I'm just going to list symptoms, but note that these fluctuate a lot: e.g. some days I'm totally out of it in the morning but get energized and alert for no apparent reason in the afternoon, some days it's exactly the other way around, etc. I'm a male in my mid-thirties.

Fatigue, brain fog, and "sluggish cognitive tempo" (thanks Wikipedia): I have been getting this on an almost daily basis recently. Thoughts come slowly, complex ideas are hard to grasp and my brain feels like it's trying to bike uphill at high gear: lots of effort and little result. When it's at its worst I have trouble thinking of words and even seem to lose some fine motor control so that I speak less clearly than usual. (I'm describing the extreme here; there are other times when I feel sharp and at the top of my mental game.) This comes with a general feeling of both physical and mental tiredness.

I'm not sleep deprived, in fact the opposite: I sleep 9-10 hours a night, because less than that doesn't feel like enough. But my sleep isn't very deep -- I wake up several times each night and am usually still sleepy in the morning.

Low mood: I was diagnosed with dysthymia some years ago, and though it got a bit better with therapy, it seems to be making a comeback. I feel generally glum, anhedonic and uninterested in things. I'm considering going on meds for depression, but want to try other avenues first. If I have some specific biochemical imbalance I want to know what it is first and whether it might be easily treatable in some other way.

My digestion seems to be off as well: I usually feel full and often a bit bloated even when I haven't eaten recently, so that I'm rarely really hungry. Still, I eat a healthy, mostly vegetarian diet. I don't eat junk food, and most days I don't consume caffeine, wheat or dairy products. I take fish oil and a multivitamin regularly. I get a moderate amount of exercise (strenuous yoga 2-3 times a week plus some biking and walking), though I do spend a whole lot of time sitting in front of a monitor, so maybe this isn't enough.

I've never been tested for ADD, but I do have a supply of Ritalin (acquired legally in a country where any MD can prescribe it) and have been experimenting with dosages. For a while it seemed like 2.5-5mg a day was fending off most of these symptoms; then that stopped working reliably, and I tried 10mg but this made me hyper and jittery, and if anything even more fogged-out (though in a strangely wired way). I also tried Piracetam for a week or two, but it made the fatigue much worse so I stopped.

Two years ago I did a general metabolic panel plus thyroid and testosterone tests. Everything came back normal, though my protein level was at the very low end of the range. It's possible that things have changed since, of course.

So how can I find out what's going on with my body/brain chemistry? Who should I go to and what tests should I get? More blood tests, and if so what specific ones (e.g. vitamin D?)? A psychiatrist for depression meds or for an ADD evaluation? A dietician of some kind? An endocrinologist? A sleep study? I'm going to schedule an appointment with my primary care physician this week, but I want to have some ideas of what to ask for.
posted by zeri to Health & Fitness (29 answers total) 21 users marked this as a favorite
IANAD etc., but it wouldn't hurt to try eating a few bananas. I've had low-potassium brain fogs that were resolved that way.
It may be many other things of course, but a banana or two won't hurt you at the very least.
posted by L'Estrange Fruit at 3:00 PM on November 3, 2013

I would suggest a couple of lifestyle fixes that have helped me (our situations are remarkably similar).

First- are you spending a lot of time in front of screens before you go to sleep? If so, try to stop that habit. Turn off the computer, the phone, the tablet, the TV, etc. at least an hour before going to bed. This really makes a big difference for me in terms of sleep quality. When I do this (which admittedly isn't often enough), I do things like listening to podcasts, listening to radio dramas, or reading books. That helps me to wind down. (Along with that, try to turn the lights down if you can, late in the evening.)

Second- are you getting regular strenuous exercise? Yoga can be really strenuous for some people, but for others, it's more of a gentle relaxation exercise. Are you really walking at a brisk 14-15 minute per mile pace, or biking at a fast pace? If none of these things are true, then some more strenuous exercise might help you a lot. My sleep and my cognitive skills improve when I am getting out and jogging at least 3-4 times a week. Plus, I also throw in mountain biking or brisk walks (at least 2 miles over the course of 30 minutes) for a couple of those other three days. The better my exercise, the better my sleep, generally. The better my sleep, the better I function the next day.

Both of these things have helped me to a degree, though I'm still trying to work with my doctor to see whether a medication might help, too.

As for blood tests, have you asked about iron levels? Low iron can really throw off your energy.

Also one last thing... can you get a good vacation soon, where you can go somewhere new, try new foods, explore new territory? It sounds like you need a break. I am not your doctor of course, but I bet your doctor will pick up on this. Maybe you just need a change of pace and a change of scenery, because you sound pretty tired and stretched thin.

I hope your doctor can give you some helpful ideas, and I would love to hear whether you find a solution that works for you. Sorry- I wish I had more feedback about brain chemistry, etc.
posted by Old Man McKay at 3:21 PM on November 3, 2013 [1 favorite]

I would be looking for a neurologist and/or psychologist (different from a psychiatrist) for cognitive testing, in order to rule out (or diagnose) any cognitive deficits or conditions.
posted by jaguar at 3:22 PM on November 3, 2013

Ditto exercise, also probiotics for the gut, keep taking 'em and add other fermented foods. Plus coconut oil for the foggy brain, add vitamin D and Omega 3 caps, cut down on sugar, carbs in general and get some real sleep. My two cents worth, your mileage may vary.
posted by diode at 3:25 PM on November 3, 2013 [6 favorites]

I had this and it turned out to be caused by arthritis; something which had bugged me so mildly and infrequently that I had not bothered to go get it diagnosed. Now I have a diagnosis I have anti-inflammatories and I am not nearly as tired.

The diagnosis required a rheumatologist and an MRI of the bit that ached.

YMM obviously V greatly.
posted by emilyw at 3:34 PM on November 3, 2013 [1 favorite]

I do have a supply of Ritalin (acquired legally in a country where any MD can prescribe it) and have been experimenting with dosages. For a while it seemed like 2.5-5mg a day was fending off most of these symptoms; then that stopped working reliably, and I tried 10mg but this made me hyper and jittery, and if anything even more fogged-out (though in a strangely wired way).

I'm not sure what you mean by "acquired legally in a country where any MD can prescribe it" and "experimenting with dosages" but if you're experimenting with dosages of Ritalin and other drugs without consulting with a doctor, I'd start there. You could be having some reactions to the medications you're taking.
posted by sweetkid at 3:39 PM on November 3, 2013 [1 favorite]

2.5 - 5 mg of Ritalin can't be nearly enough. You didn't mention your weight, but for most people, 5 is just a starting dose, and even then it lasts for 2, 2.5 hours. You have to keep taking Ritalin during the day in order for it to work. The last attempt was 10, 15, 15, 10 I think during the day, so a total of 50 mg a day. I discontinued Ritalin though, because it was too strenuous after a few days, and I'd just go on a weird anxiety trip.

Anyway, for any kind of stimulant you have to find the right dosage with a physician, which usually takes time. "Experimenting with dosages" is more complicated than just giving it a shot.
posted by ahtlast93 at 4:14 PM on November 3, 2013 [1 favorite]

Even before you got to the comment about low protein, I was thinking "this sounds like me when I haven't eaten any protein yet that day." Protein, maybe even meat, might be something to try. (No disrespect to vegetarianism intended. I know it works well for some people. But I was vegetarian for a decade and vegan for two years, and my body seems to work better when I include meat in my diet.)
posted by slidell at 4:32 PM on November 3, 2013 [1 favorite]

They always or almost always give me the following blood tests: Sometimes, when I feel worse, I also get:
  • Vitamin D
  • Folate/B12 (folate supplmentation can impact the effectiveness of antidepressants, in addition to folate deficiency in itself causing depressive symptoms)
  • C-Reactive Protein and other inflammation-related stuff, because a bunch of inflammatory conditions can cause depressive symptoms (particularly the fatigue and mental fuzziness.)
Inflammation tests also help rule out infectious causes (depression mimics how a lot of people act when they've got the flu or the measles or whatever - it's called "sickness behavior.")

I agree with those above who advocate against "experimenting" on your own with psych meds. Even the professional psychiatric community isn't sure what will happen with individual patients; that's the main reason they monitor you so closely at first on the darned things (in many cases, we still don't know how or why the medications work.) A paradoxical reaction can't be ruled out over the internet. And there's a small, but non-zero, chance that the stimulant is screwing with your heart even at this dosage, which can wreak all kinds of havoc with how you feel. I get periodic heart monitoring now as well, and I'm on a barely-there dose of Adderall.

Oh, and in a happy perfect world I'd agree about going to a psychologist for cognitive testing, but it can be challenging to get insurance to pay for it. Neurologists usually have an easier time getting reimbursement, at least under every plan I've been on. Most psychologists around here won't even bill directly to insurance for that kind of testing, since they rarely see anyone who's definitely gong to get paid for (head trauma, Alzheimer's, etc.) I know this because it actually explicitly says that on their websites - mental health professionals are usually pretty open about their pricing and billing issues for exactly this kind of reason.
posted by Fee Phi Faux Phumb I Smell t'Socks o' a Puppetman! at 4:52 PM on November 3, 2013 [4 favorites]

I'm not sleep deprived, in fact the opposite: I sleep 9-10 hours a night, because less than that doesn't feel like enough. But my sleep isn't very deep -- I wake up several times each night and am usually still sleepy in the morning.

IANAD or even remotely close, but this sentence rings alarm bells to me that you may have some kind of sleeping disorder. You may want to see a sleep specialist and possibly get a sleep study done (one of those deals where you sleep at the test center overnight).

Many of your symptoms sound like they could be a result of sleep deprivation caused by poor quality sleep, even if you are technically sleeping 9-10 hours.
posted by mekily at 4:55 PM on November 3, 2013 [4 favorites]

Since you said your sleep is not very good, I'd start there. There is tons of info about sleep hygiene on the net, I'd look that up. I notice a huge difference in my cognitive ability on days I sleep well and days I don't. Remember, it's not the time spent in sleep, but the quality. You should be getting consistent good sleep as you can still feel the effects of a bad night sleep after the 2nd day. Fish oil, coconut oil, exercise help too.
posted by eq21 at 4:57 PM on November 3, 2013

Your GP can give you a general blood test, then you can go from there. It makes sense to start with a GP before going to a specialist. After GP, specialists you can try might include neurologist and rheumatologist.

In your shoes, I'd minimize the Ritalin use because it can be habit forming and burn you out longer term. I know because I used it (legally) during the end of my dissertation. Adderall was better for me (smoother longer release) anyway. But taking it still had long term negative effects for me. It covered up my fatigue, but I kept overfatiguing myself even more and there was hell to pay when it was all over.

Strangely enough, what helped me during dissertation brain fog was not stimulants but sleeping pills. I had such anxiety that I wasn't sleeping well. Once or twice per week (sometimes less) I took Ambien to get a really deep night of sleep. I took it at the right time, so no being a night owl. It helped a lot.

I think the best thing a doctor can do is take a really detailed health history, and try to understand if anything has changed in your life that might cause this. Diet changes? Seasonal change? Long term, chronic stress can do it. I got similar brain fog for months after my Ph.D., literally months. I was so slow that it was scary, because my whole life, my sharp thinking has been my main skill. It took months to resolve. It was really scary to me. 11 months after graduation I'm operating at 75-80%, which is good but still not fully resolved.

I had a friend who felt this way because he was allergic to mold in his apartment. When he moved, it cleared up.

Basically, what a doctor will do is try to figure it out by process of elimination. Start with the most obvious causes and their most obvious cures. You only take out the big guns and specialists if normal cures have not helped. Diagnosing the cause of chronic fatigue is hard. GP, neurologist, and rheumatologist could be good places to start. GP for the bloodwork panel.
posted by htid at 5:08 PM on November 3, 2013 [1 favorite]

I spent years sleeping poorly, rotating through all kinds of sleep meds, and still waking up several times a night and getting poor quality sleep. I got a sleep test. Lo and behold, I have severe sleep apnea. I sleep with a CPAP and the quality of my sleep is 100% better, and I'm able to get by with far less medication. The quality of my waking life has also improved tremendously.

Sleep apnea is often stereotyped as something that only fat, middle-aged men who snore like bears get. No! You can be young, thin, and female, not snore (or not snore very loudly) and still have sleep apnea. (I have a "crowded airway" - that is, a small jaw, large teeth and tongue - which contributes to my apnea.) If you are a young woman, and especially if you are not overweight, you may have to really push to get a sleep test. But do get one! If your sleep is not refreshing, there is almost always something you can do about it, and you will feel so much better.
posted by Rosie M. Banks at 5:13 PM on November 3, 2013 [1 favorite]

I felt exactly like you and I had a MAJOR vitamin D deficiency. Doc prescribed a temporary mega does and I'm now on a daily Vit D3 pill. This made ALL the difference in the world for me. I do think a complete blood workup would be smart.

Best wishes for a speedy diagnosis and recovery.
posted by michellenoel at 5:27 PM on November 3, 2013

Have you tried cutting all the wheat and taking some B12? Gluten intolerance can cause a lot of trouble with digestion like you described, and B12 absorption which may already be an issue from your diet.
posted by bongo_x at 5:29 PM on November 3, 2013 [1 favorite]

I'd consider trying antidepressants sooner rather than later, especially since you've been diagnosed with dysthymia. They've helped me. Regular exercise seems to help my brain, too. And - this will sound dumb and obvious - but my brain gets foggy when I'm regularly bored or stressed, and eliminating those sources of stress when I can helps me. (FWIW, Ritalin did nothing for me.)

Other than that, I agree with the advice to see a neurologist.
posted by Metroid Baby at 5:46 PM on November 3, 2013

I was experiencing similar symptoms, albeit different ones. Go to your doctor and explain your symptoms, and request an MRI to look for lesions on your brain. He'll take it from there. I won't tell you my diagnosis but you need to get it checked out sooner rather than later.
posted by squirbel at 5:52 PM on November 3, 2013

I was diagnosed with hypopituitarism and have many similar symptoms as you. Your GP will direct you to the appropriate specialist. I went to an endocronogist who specialized in fatigue disorders. Your symptoms also are quite similar to chronic fatigue syndrome. You may want to research CFS and the specialists in your area who treat it. It makes a big difference going to specialists who treat fatigue disorders. The book I read was From Fatigued To Fantastic and it lists a bunch of CFS symptoms right on the cover. IANAD.
posted by wildflower at 6:25 PM on November 3, 2013

I advise getting all of the medical concerns checked out, especially the sleep apnea. But also, as someone in a very, very similar position life-wise... everything about this sounds like grad school related stress and burnout to me.

You're wondering why you're exhausted, you don't want to get out of bed, you're have trouble concentrating, you've lost your appetite, and generally feel glum, anhedonic, and uninterested in everything...and in the last month it's been way worse than usual? Well, dog, it's job application season. You dropped that in there like an afterthought, but I don't know anybody suffering through the psychological hell that is the academic job market who doesn't feel basically the way you've described. Because. it. fucking. sucks.

Look, I don't know if that's what's going on with you, and I in no way mean this in a "buck up, buddy, that's just the process, pull up your socks and deal with it" kind of way. I mean it in a "I've witnessed this wreak havoc on the mental and physical well being of a lot of people I care about and it scares and angers me" kind of way. And while eating more protein and potassium and exercising a ton and maybe getting a CPAP are all awesome ideas and could help you get through a difficult process, Ritalin and anti-depressants are a different story.

Sometimes people are depressed and anxious because their brains aren't working right. And sometimes they're depressed and anxious because the situation they're in is harmful and bad, and their brains are telling them so. It is really, really hard to tell the difference. If your GP is like most of the doctors I've encountered in an academic setting, they'll write you a prescription for Ritalin or Prozac basically on request. And the truth is that even if you aren't clinically depressed, drugs will probably take the edge off your misery. But if any of this rings true for you, don't ask for that right away. Start talk therapy first, with someone who's experienced in dealing with people in this situation. Because the problem might not be you.
posted by pretentious illiterate at 7:20 PM on November 3, 2013 [3 favorites]

I actually do agree that it could all be psychological, but it's most helpful to get the physical stuff ruled out first. Good therapists will send you to a doctor first if you're having cognitive issues -- it's frustrating to do all the psychological work you can, and still not get any better because there's a physical issue. Medical/physical issues are usually easier to diagnose than psychological ones, so it makes sense to rule those out first.
posted by jaguar at 7:29 PM on November 3, 2013 [1 favorite]

You're not alone - so much of what you described is what I've been battling for about four years now. I'm also working on a dissertation (though the diss postdates the onset of symptoms) and finding it difficult to meet any kind of reasonable standard due to just not thinking clearly, among other things. I've finally determined to make my university's health services (not the best health care, but it's all that's available to me) figure out what's going on, if by no other means than constantly going back and asking them to try other things when the standard tests reveal nothing unusual. I'm hopeful something will be found eventually. The closest I've gotten to anything abnormal is an apparent recent case of Epstein-Barr virus, but they tell me that's not anything that can be treated or should have long-term effects. I'm going back on Tuesday to ask for hormone testing.

Anyhow, I just want you to know you're not the only one battling through a fog. The best of luck to you, and please keep me posted if you get any answers. I can do the same for you, if you like, if we may be suffering something related.
posted by AthenaPolias at 7:42 PM on November 3, 2013

Is anyone else around you similarly sick? Are you in shared housing? My family has just had a several-month bout of mycoplasma pneumonia which is a very slow running bacterial infection that shows up as a mild chronic flu in most people, and in a lucky few like me, flu without the fever or sniffles, just the fog and fatigue. We had to do blood tests and almost all of us take a specific antibiotic for over a month. It's not very common but I thought I was just depressed with a cold at first, and finally getting the right antibiotics was all "I can do stuff again!"

I would definitely go to a GP for a health work-up first because this is a significant and relatively fast change. It's unlikely to be mycoplasma (it's common in my country, and in clusters, so all of us getting sick was a pointer) but it could be thyroid issues, arthritis etc.
posted by viggorlijah at 9:04 PM on November 3, 2013

That's tough to feel that way. As for causes, there could be so many reasons. I agree with other other posters about getting testing. When I mention similar symptoms to my doctor, I get a thyroid panel and Vit D panel. Pretty low Vit D caused me to have an apathetic mood, fatigue, sleeping, and stomach issues in the past. Not sure if all those problems were related, but I felt better after a 12 weeks of taking a high dose Vitamin D pill weekly. One thing the doctor could also test is your stool in case you have a stomach infection causing those symptoms.

If the initial testing by a primary does not work out, I suggest seeking help from a therapist in case it is related to the dysthymia or depression.

Also, exercise helps the mood and the stomach issues. I found low to moderate amounts consistently (30-45 mins, three to five times a week) help better than doing strenuous activities as it keeps the body more balanced.

It's possible that all of it could be stress and poor sleep hygiene. Try not to think too much about things before bed and do a relaxing activity instead.
posted by LadyAerin at 11:01 PM on November 3, 2013

I'm right there with mekily. If you are getting the right quantity of sleep, but it's not doing the trick, it's entirely possible you have some kind of apnea going on. That would also be consistent with the other symptoms you describe.

Definitely get a sleep study. I can't hurt.
posted by colin_l at 12:45 AM on November 4, 2013

When I had fatigue and brain fog like that earlier this year, it ended up being mono. It varied throughout the day too, usually hitting me worst at 3pm. My brain slowed right down if I did something physically strenuous like walking to work (at this point, that counted as strenuous because it took any effort at all). My walking speed was one third my usual pace.

I initially tested negative for mono, but tested positive for a (reactivated) Epstein-Barr infection, likely triggered by stress. I ended up taking a week or 2 off to sleep and it eased off. It's amazing how crippling that brain fog can be.
posted by heatherann at 4:37 AM on November 4, 2013

It sounds like you have more than enough on your plate to cause these symptoms and then some. In ref to jaguar, I have to say that vague-ish symptoms like this are amongst the most difficult to diagnose physically. I spent over 20 years being sent from doctor to doctor, to psychologists, psychiatrists, endocrinologists (who missed the diagnosis) and many other specialists whilst getting progressively more ill and incapacitated. Eventually in desperation, through my own efforts, I persuaded a doc to do tests for and was diagnosed with Addison's Disease-notoriously difficult to diagnose and very rare. One pill in the morning for the last 10 years and I'm full of energy and all systems have stabilized.

Some of my many symptoms were like yours OP-sleeping 9-10 hours and not able to function on less, fatigue, low mood, endless digestion problems, brain fog and more. I tried everything incl anti-depressants. They didn't do much ,if anything, except give me side effects.

Not suggesting you OP have the same. To me your symptoms sound more like reactive stress- seconding the change of scene. Just pointing out physical diagnosis is not always easy at all with vague symptoms-I had no abnormal tests (aside from the unusual one I finally demanded) and looking back the only sign docs could have picked up on was very low blood pressure but they always said "That's great you want it low!' Well I didn't. After diagnosis, BP became normal and I felt normal, not like I was dying a slow death (which is what adrenal failure feels like and is).
posted by claptrap at 6:23 AM on November 4, 2013

Ask your doctor to test you for lyme disease. (There a number of tests they can do to check for lyme disease; you'll want them to do the tests that check for early and late infections.)
posted by emilynoa at 11:41 AM on November 4, 2013

There are a number of things listed above that could cause what you are describing. Based on your description and my own experience, you sound like I felt before being treated for hypothyroid and sleep apnea. Regardless, I would suggest making a detailed list of your symptoms to discuss with your doctor. If you have a roommate or romantic partner, that person might be able to help you answer questions about your sleep (do you snore? do you wake up gasping? do you toss and turn a lot in your sleep? etc.)

Good luck!
posted by oblique red at 12:17 PM on November 5, 2013


I'm posting this because I was in your position 6 months ago and was reading metafilter and didn't get any good answers. I went from working on wall street to wanting to sleep all day within a period of 6 months and didn't know why. I am 25 years old and have Hashimoto's disease, which is one of the most common causes of the symptoms that you are experiencing and is an vastly under-diagnosed illness. Here is what I recommend:

Here are the don'ts.
1) Don't let anyone tell you to ignore how you feel ever! Do not let anyone tell you it is in your head. It is not in your head and no one deserves to feel this way. Do not believe stuff like "this too shall pass" unless you know that there is nothing medically wrong with you. Not everything is in your head and if you experience persistent cases of fatigue despite sleeping properly, eating properly, and being pretty young, then it is not in your head. There is a difference between "being a fighter" and knowing when people telling you "get over it" are full of crap.
2) Do not let anyone tell you "diet and exercise" is the reason why you are feeling this way. Diet is a very large component of our health and so is exercise, but it is important to call bullshit on this when it is appropriate. In my case, I had probably the healthiest lifestyle of all of my friends and yet I still felt this way. This was a warning sign that the cause of my fatigue was NOT due to lifestyle factors alone. If you are the same way, then do NOT fool around with diet and exercise thinking that this alone will fix your problem.
3) Do not go to just any doctor and expect that they will have a solution to your problem. Doctors are very poor at diagnosing vague illnesses where the symptom is fatigue. Doctors are trained such that they need clear physical symptoms to assess what is wrong. Moreover, most doctors have their hands tied in running bloodwork in that insurance companies, since insurance companies often are skimpy on paying for proper testing.
4) DO NOT let them diagnose you with depression or something similar unless you have been checked for hormonal issues first. SO MUCH research shows that cases of persistent depression/fatigue is actually a hormonal issue it's not even funny. Most doctors do not know this. [BUT if you can rule out underlying health causes, then depression is a perfectly legitimate diagnosis and you should get properly treated for it!]

Here are the do's:
1) Go to a rating website for doctors like Vitals dot com or a similar site (just google for doctor rating website) and find the very BEST doctors in your area. For vague issues like fatigue it is of UTMOST importance to see a very good doctor for a diagnosis, since only they will have the balls to get all the proper testing done. DEMAND that you get a full bloodwork done. Use the internet as a starting point to suggest a few things to the doctor and to help you be assertive, but at the end of the day a great doctor is going to help you far more than metafilter is.
2) DEMAND that you get proper hormone testing and endocrine testing done. If your primary care physician will not do it, see an endocrinologist. If they refuse you, keep calling endocrinologists until one will see you without a referring physician. Do not put up with their crap if you are suffering and cannot get the proper tests done.
3) Be your own advocate. Once you get a diagnosis, find the best doctor you can afford. Learn as much as you can about your illness so that you can live the healthiest life that you can.

Best of luck.
posted by sben789 at 8:33 PM on May 13, 2014 [1 favorite]

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