Reticular Hyperpigmentation With Keratotic Papules in the Axillae and Groin

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The Diagnosis: Galli-Galli Disease

Several cutaneous conditions can present as reticulated hyperpigmentation or keratotic papules. Although genetic testing can help identify some of these dermatoses, biopsy typically is sufficient for diagnosis, and genetic testing can be considered for more clinically challenging cases. In our case, the clinical evidence and histopathologic findings were diagnostic of Galli-Galli disease (GGD), an autosomal-dominant genodermatosis with incomplete penetrance. Our patient was unaware of any family members with a diagnosis of GGD; however, she reported a great uncle with similar clinical findings.

Galli-Galli disease is a rare allelic variant of Dowling- Degos disease (DDD), both caused by a loss-of-function mutation in the keratin 5 gene, KRT5. Both conditions present as reticulated papules distributed symmetrically in the flexural regions, most commonly the axillae and groin, but also as comedolike papules, typically in patients aged 30 to 50 years.1 Cutaneous lesions primarily are of cosmetic concern but can be extremely pruritic, especially for patients with GGD. Gene mutations in protein O-fucosyltransferase 1, POFUT1; protein O-glucosyltransferase 1, POGLUT1; and presenilin enhancer 2, PSENEN, also have been discovered in cases of DDD and GGD.2,3

Galli-Galli disease and DDD are distinguishable by their histologic appearance. Both diseases show elongated fingerlike rete ridges and a thin suprapapillary epidermis. The basal projections often are described as bulbous or resembling antler horns.4 Galli-Galli disease can be differentiated from DDD by focal suprabasal acantholysis with minimal dyskeratosis (quiz images).5 Due to the genetic and clinical similarities, many consider GGD an acantholytic variant of DDD rather than its own entity. Indeed, some patients have shown acantholysis in one area of biopsy but not others.6

Hailey-Hailey disease (HHD)(also known as benign familial or benign chronic pemphigus) is an autosomaldominant disorder caused by mutation of the ATPase secretory pathway Ca2+ transporting 1 gene, ATP2C1. Clinically, patients tend to present at a wide age range with fragile flaccid vesicles that commonly develop on the neck, axillae, and groin. Histologically, the epidermis is acanthotic with a dilapidated brick wall– like appearance from a few persistent intercellular connections amid widespread acantholysis (Figure 1).7 Unlike in autoimmune pemphigus, direct immunofluorescence is negative, and acantholysis spares the adnexal structures. Hailey-Hailey disease does not involve reticulated hyperpigmentation or the elongated bulbous rete seen in GGD. Confluent and reticulated papillomatosis is a rare, typically asymptomatic, hyperpigmented dermatosis. It presents as a conglomeration of scaly hyperpigmented macules or papillomatous papules that coalesce centrally and are reticulated toward the periphery.

Hailey-Hailey disease
FIGURE 1. Hailey-Hailey disease. An acanthotic epidermis with suprabasal and intraepidermal acantholysis of keratinocytes resembling a dilapidated brick wall (H&E, original magnification ×100).

Confluent and reticulated papillomatosis most commonly is seen on the trunk, initially presenting in adolescents and young adults. Confluent and reticulated papillomatosis is histologically similar to acanthosis nigricans. Histopathology will show hyperkeratosis, papillomatosis, and minimal to no inflammatory infiltrate, with no elongated rete ridges or acantholysis (Figure 2).8

Confluent and reticulated papillomatosis
FIGURE 2. Confluent and reticulated papillomatosis. Hyperkeratosis, papillomatosis, and a sparse perivascular lymphocytic infiltrate (H&E, original magnification ×40).

Pemphigus vulgaris is a blistering disease resulting from the development of autoantibodies against desmogleins 1 and 3. Similar to GGD, there is suprabasal acantholysis, which often results in a tombstonelike appearance consisting of separation between the basal layer cells of the epidermis but with maintained attachment to the underlying basement membrane zone. Unlike HHD, the acantholysis tends to involve the follicular epithelium in pemphigus vulgaris (Figure 3). Clinically, the blisters are positive for Nikolsky sign and can be both cutaneous or mucosal, commonly arising initially in the mouth during the fourth or fifth decades of life. Ruptured blisters can result in painful and hemorrhagic erosions.9 Direct immunofluorescence exhibits a classic chicken wire–like deposition of IgG and C3 between keratinocytes of the epidermis. Although sometimes difficult to appreciate, the deposition can be more prominent in the lower epidermis, in contrast to pemphigus foliaceus, which can have more prominent deposition in the upper epidermis.

Pemphigus vulgaris.
FIGURE 3. Pemphigus vulgaris. Acantholysis of the lower stratum spinosum and the hair follicle forming an intraepidermal blister (H&E, original magnification ×100).

Darier disease (or dyskeratosis follicularis) is an autosomal-dominant genodermatosis caused by mutation of the ATPase sarcoplasmic/endoplasmic reticulum Ca2+ transporting 2 gene, ATP2A2. Clinically, this disorder arises in adolescents as red-brown, greasy, crusted papules in seborrheic areas that may coalesce into papillomatous clusters. Palmar punctate keratoses and pits also are common. Histologically, Darier disease can appear similar to GGD, as both can show acantholysis and dyskeratosis. Darier disease will tend to show more prominent dyskeratosis with corps ronds and grains, as well as thicker villilike projections of keratinocytes into the papillary dermis, in contrast to the thinner, fingerlike or bulbous projections that hang down from the epidermis in GGD (Figure 4).10

Darier disease
FIGURE 4. Darier disease. Parakeratotic hyperkeratosis and acantholytic dyskeratosis with corps ronds and grains (H&E, original magnification ×100).
References
  1. Hanneken S, Rütten A, Eigelshoven S, et al. Morbus Galli-Galli. Hautarzt. 2013;64:282.
  2. Wilson NJ, Cole C, Kroboth K, et al. Mutations in POGLUT1 in Galli- Galli/Dowling-Degos disease. Br J Dermatol. 2017;176:270-274.
  3. Ralser DJ, Basmanav FB, Tafazzoli A, et al. Mutations in γ-secretase subunit–encoding PSENEN underlie Dowling-Degos disease associated with acne inversa. J Clin Invest. 2017;127:1485-1490.
  4. Desai CA, Virmani N, Sakhiya J, et al. An uncommon presentation of Galli-Galli disease. Indian J Dermatol Venereol Leprol. 2016; 82:720-723.
  5. Joshi TP, Shaver S, Tschen J. Exacerbation of Galli-Galli disease following dialysis treatment: a case report and review of aggravating factors. Cureus. 2021;13:E15401.
  6. Muller CS, Pfohler C, Tilgen W. Changing a concept—controversy on the confusion spectrum of the reticulate pigmented disorders of the skin. J Cutan Pathol. 2008;36:44-48.
  7. Dai Y, Yu L, Wang Y, et al. Case report: a case of Hailey-Hailey disease mimicking condyloma acuminatum and a novel splice-site mutation of ATP2C1 gene. Front Genet. 2021;12:777630.
  8. Banjar TA, Abdulwahab RA, Al Hawsawi KA. Confluent and reticulated papillomatosis of Gougerot and Carteaud: a case report and review of the literature. Cureus. 2022;14:E24557.
  9. Porro AM, Seque CA, Ferreira MCC, et al. Pemphigus vulgaris. An Bras Dermatol. 2019;94:264-278.
  10. Bachar-Wikström E, Wikström JD. Darier disease—a multi-organ condition? Acta Derm Venereol. 2021;101:adv00430.
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Jefferson Waters is from Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania. Drs. Desrosiers, Flint, and Ferringer are from the Department of Dermatology, Geisinger Medical Center, Danville, Pennsylvania. Dr. Ferringer also is from the Department of Laboratory Medicine.

The authors report no conflict of interest.

Correspondence: Jefferson Waters, BA, Geisinger Commonwealth School of Medicine, 525 Pine St, Scranton, PA 18510 ([email protected]).

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Jefferson Waters is from Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania. Drs. Desrosiers, Flint, and Ferringer are from the Department of Dermatology, Geisinger Medical Center, Danville, Pennsylvania. Dr. Ferringer also is from the Department of Laboratory Medicine.

The authors report no conflict of interest.

Correspondence: Jefferson Waters, BA, Geisinger Commonwealth School of Medicine, 525 Pine St, Scranton, PA 18510 ([email protected]).

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Jefferson Waters is from Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania. Drs. Desrosiers, Flint, and Ferringer are from the Department of Dermatology, Geisinger Medical Center, Danville, Pennsylvania. Dr. Ferringer also is from the Department of Laboratory Medicine.

The authors report no conflict of interest.

Correspondence: Jefferson Waters, BA, Geisinger Commonwealth School of Medicine, 525 Pine St, Scranton, PA 18510 ([email protected]).

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The Diagnosis: Galli-Galli Disease

Several cutaneous conditions can present as reticulated hyperpigmentation or keratotic papules. Although genetic testing can help identify some of these dermatoses, biopsy typically is sufficient for diagnosis, and genetic testing can be considered for more clinically challenging cases. In our case, the clinical evidence and histopathologic findings were diagnostic of Galli-Galli disease (GGD), an autosomal-dominant genodermatosis with incomplete penetrance. Our patient was unaware of any family members with a diagnosis of GGD; however, she reported a great uncle with similar clinical findings.

Galli-Galli disease is a rare allelic variant of Dowling- Degos disease (DDD), both caused by a loss-of-function mutation in the keratin 5 gene, KRT5. Both conditions present as reticulated papules distributed symmetrically in the flexural regions, most commonly the axillae and groin, but also as comedolike papules, typically in patients aged 30 to 50 years.1 Cutaneous lesions primarily are of cosmetic concern but can be extremely pruritic, especially for patients with GGD. Gene mutations in protein O-fucosyltransferase 1, POFUT1; protein O-glucosyltransferase 1, POGLUT1; and presenilin enhancer 2, PSENEN, also have been discovered in cases of DDD and GGD.2,3

Galli-Galli disease and DDD are distinguishable by their histologic appearance. Both diseases show elongated fingerlike rete ridges and a thin suprapapillary epidermis. The basal projections often are described as bulbous or resembling antler horns.4 Galli-Galli disease can be differentiated from DDD by focal suprabasal acantholysis with minimal dyskeratosis (quiz images).5 Due to the genetic and clinical similarities, many consider GGD an acantholytic variant of DDD rather than its own entity. Indeed, some patients have shown acantholysis in one area of biopsy but not others.6

Hailey-Hailey disease (HHD)(also known as benign familial or benign chronic pemphigus) is an autosomaldominant disorder caused by mutation of the ATPase secretory pathway Ca2+ transporting 1 gene, ATP2C1. Clinically, patients tend to present at a wide age range with fragile flaccid vesicles that commonly develop on the neck, axillae, and groin. Histologically, the epidermis is acanthotic with a dilapidated brick wall– like appearance from a few persistent intercellular connections amid widespread acantholysis (Figure 1).7 Unlike in autoimmune pemphigus, direct immunofluorescence is negative, and acantholysis spares the adnexal structures. Hailey-Hailey disease does not involve reticulated hyperpigmentation or the elongated bulbous rete seen in GGD. Confluent and reticulated papillomatosis is a rare, typically asymptomatic, hyperpigmented dermatosis. It presents as a conglomeration of scaly hyperpigmented macules or papillomatous papules that coalesce centrally and are reticulated toward the periphery.

Hailey-Hailey disease
FIGURE 1. Hailey-Hailey disease. An acanthotic epidermis with suprabasal and intraepidermal acantholysis of keratinocytes resembling a dilapidated brick wall (H&E, original magnification ×100).

Confluent and reticulated papillomatosis most commonly is seen on the trunk, initially presenting in adolescents and young adults. Confluent and reticulated papillomatosis is histologically similar to acanthosis nigricans. Histopathology will show hyperkeratosis, papillomatosis, and minimal to no inflammatory infiltrate, with no elongated rete ridges or acantholysis (Figure 2).8

Confluent and reticulated papillomatosis
FIGURE 2. Confluent and reticulated papillomatosis. Hyperkeratosis, papillomatosis, and a sparse perivascular lymphocytic infiltrate (H&E, original magnification ×40).

Pemphigus vulgaris is a blistering disease resulting from the development of autoantibodies against desmogleins 1 and 3. Similar to GGD, there is suprabasal acantholysis, which often results in a tombstonelike appearance consisting of separation between the basal layer cells of the epidermis but with maintained attachment to the underlying basement membrane zone. Unlike HHD, the acantholysis tends to involve the follicular epithelium in pemphigus vulgaris (Figure 3). Clinically, the blisters are positive for Nikolsky sign and can be both cutaneous or mucosal, commonly arising initially in the mouth during the fourth or fifth decades of life. Ruptured blisters can result in painful and hemorrhagic erosions.9 Direct immunofluorescence exhibits a classic chicken wire–like deposition of IgG and C3 between keratinocytes of the epidermis. Although sometimes difficult to appreciate, the deposition can be more prominent in the lower epidermis, in contrast to pemphigus foliaceus, which can have more prominent deposition in the upper epidermis.

Pemphigus vulgaris.
FIGURE 3. Pemphigus vulgaris. Acantholysis of the lower stratum spinosum and the hair follicle forming an intraepidermal blister (H&E, original magnification ×100).

Darier disease (or dyskeratosis follicularis) is an autosomal-dominant genodermatosis caused by mutation of the ATPase sarcoplasmic/endoplasmic reticulum Ca2+ transporting 2 gene, ATP2A2. Clinically, this disorder arises in adolescents as red-brown, greasy, crusted papules in seborrheic areas that may coalesce into papillomatous clusters. Palmar punctate keratoses and pits also are common. Histologically, Darier disease can appear similar to GGD, as both can show acantholysis and dyskeratosis. Darier disease will tend to show more prominent dyskeratosis with corps ronds and grains, as well as thicker villilike projections of keratinocytes into the papillary dermis, in contrast to the thinner, fingerlike or bulbous projections that hang down from the epidermis in GGD (Figure 4).10

Darier disease
FIGURE 4. Darier disease. Parakeratotic hyperkeratosis and acantholytic dyskeratosis with corps ronds and grains (H&E, original magnification ×100).

The Diagnosis: Galli-Galli Disease

Several cutaneous conditions can present as reticulated hyperpigmentation or keratotic papules. Although genetic testing can help identify some of these dermatoses, biopsy typically is sufficient for diagnosis, and genetic testing can be considered for more clinically challenging cases. In our case, the clinical evidence and histopathologic findings were diagnostic of Galli-Galli disease (GGD), an autosomal-dominant genodermatosis with incomplete penetrance. Our patient was unaware of any family members with a diagnosis of GGD; however, she reported a great uncle with similar clinical findings.

Galli-Galli disease is a rare allelic variant of Dowling- Degos disease (DDD), both caused by a loss-of-function mutation in the keratin 5 gene, KRT5. Both conditions present as reticulated papules distributed symmetrically in the flexural regions, most commonly the axillae and groin, but also as comedolike papules, typically in patients aged 30 to 50 years.1 Cutaneous lesions primarily are of cosmetic concern but can be extremely pruritic, especially for patients with GGD. Gene mutations in protein O-fucosyltransferase 1, POFUT1; protein O-glucosyltransferase 1, POGLUT1; and presenilin enhancer 2, PSENEN, also have been discovered in cases of DDD and GGD.2,3

Galli-Galli disease and DDD are distinguishable by their histologic appearance. Both diseases show elongated fingerlike rete ridges and a thin suprapapillary epidermis. The basal projections often are described as bulbous or resembling antler horns.4 Galli-Galli disease can be differentiated from DDD by focal suprabasal acantholysis with minimal dyskeratosis (quiz images).5 Due to the genetic and clinical similarities, many consider GGD an acantholytic variant of DDD rather than its own entity. Indeed, some patients have shown acantholysis in one area of biopsy but not others.6

Hailey-Hailey disease (HHD)(also known as benign familial or benign chronic pemphigus) is an autosomaldominant disorder caused by mutation of the ATPase secretory pathway Ca2+ transporting 1 gene, ATP2C1. Clinically, patients tend to present at a wide age range with fragile flaccid vesicles that commonly develop on the neck, axillae, and groin. Histologically, the epidermis is acanthotic with a dilapidated brick wall– like appearance from a few persistent intercellular connections amid widespread acantholysis (Figure 1).7 Unlike in autoimmune pemphigus, direct immunofluorescence is negative, and acantholysis spares the adnexal structures. Hailey-Hailey disease does not involve reticulated hyperpigmentation or the elongated bulbous rete seen in GGD. Confluent and reticulated papillomatosis is a rare, typically asymptomatic, hyperpigmented dermatosis. It presents as a conglomeration of scaly hyperpigmented macules or papillomatous papules that coalesce centrally and are reticulated toward the periphery.

Hailey-Hailey disease
FIGURE 1. Hailey-Hailey disease. An acanthotic epidermis with suprabasal and intraepidermal acantholysis of keratinocytes resembling a dilapidated brick wall (H&E, original magnification ×100).

Confluent and reticulated papillomatosis most commonly is seen on the trunk, initially presenting in adolescents and young adults. Confluent and reticulated papillomatosis is histologically similar to acanthosis nigricans. Histopathology will show hyperkeratosis, papillomatosis, and minimal to no inflammatory infiltrate, with no elongated rete ridges or acantholysis (Figure 2).8

Confluent and reticulated papillomatosis
FIGURE 2. Confluent and reticulated papillomatosis. Hyperkeratosis, papillomatosis, and a sparse perivascular lymphocytic infiltrate (H&E, original magnification ×40).

Pemphigus vulgaris is a blistering disease resulting from the development of autoantibodies against desmogleins 1 and 3. Similar to GGD, there is suprabasal acantholysis, which often results in a tombstonelike appearance consisting of separation between the basal layer cells of the epidermis but with maintained attachment to the underlying basement membrane zone. Unlike HHD, the acantholysis tends to involve the follicular epithelium in pemphigus vulgaris (Figure 3). Clinically, the blisters are positive for Nikolsky sign and can be both cutaneous or mucosal, commonly arising initially in the mouth during the fourth or fifth decades of life. Ruptured blisters can result in painful and hemorrhagic erosions.9 Direct immunofluorescence exhibits a classic chicken wire–like deposition of IgG and C3 between keratinocytes of the epidermis. Although sometimes difficult to appreciate, the deposition can be more prominent in the lower epidermis, in contrast to pemphigus foliaceus, which can have more prominent deposition in the upper epidermis.

Pemphigus vulgaris.
FIGURE 3. Pemphigus vulgaris. Acantholysis of the lower stratum spinosum and the hair follicle forming an intraepidermal blister (H&E, original magnification ×100).

Darier disease (or dyskeratosis follicularis) is an autosomal-dominant genodermatosis caused by mutation of the ATPase sarcoplasmic/endoplasmic reticulum Ca2+ transporting 2 gene, ATP2A2. Clinically, this disorder arises in adolescents as red-brown, greasy, crusted papules in seborrheic areas that may coalesce into papillomatous clusters. Palmar punctate keratoses and pits also are common. Histologically, Darier disease can appear similar to GGD, as both can show acantholysis and dyskeratosis. Darier disease will tend to show more prominent dyskeratosis with corps ronds and grains, as well as thicker villilike projections of keratinocytes into the papillary dermis, in contrast to the thinner, fingerlike or bulbous projections that hang down from the epidermis in GGD (Figure 4).10

Darier disease
FIGURE 4. Darier disease. Parakeratotic hyperkeratosis and acantholytic dyskeratosis with corps ronds and grains (H&E, original magnification ×100).
References
  1. Hanneken S, Rütten A, Eigelshoven S, et al. Morbus Galli-Galli. Hautarzt. 2013;64:282.
  2. Wilson NJ, Cole C, Kroboth K, et al. Mutations in POGLUT1 in Galli- Galli/Dowling-Degos disease. Br J Dermatol. 2017;176:270-274.
  3. Ralser DJ, Basmanav FB, Tafazzoli A, et al. Mutations in γ-secretase subunit–encoding PSENEN underlie Dowling-Degos disease associated with acne inversa. J Clin Invest. 2017;127:1485-1490.
  4. Desai CA, Virmani N, Sakhiya J, et al. An uncommon presentation of Galli-Galli disease. Indian J Dermatol Venereol Leprol. 2016; 82:720-723.
  5. Joshi TP, Shaver S, Tschen J. Exacerbation of Galli-Galli disease following dialysis treatment: a case report and review of aggravating factors. Cureus. 2021;13:E15401.
  6. Muller CS, Pfohler C, Tilgen W. Changing a concept—controversy on the confusion spectrum of the reticulate pigmented disorders of the skin. J Cutan Pathol. 2008;36:44-48.
  7. Dai Y, Yu L, Wang Y, et al. Case report: a case of Hailey-Hailey disease mimicking condyloma acuminatum and a novel splice-site mutation of ATP2C1 gene. Front Genet. 2021;12:777630.
  8. Banjar TA, Abdulwahab RA, Al Hawsawi KA. Confluent and reticulated papillomatosis of Gougerot and Carteaud: a case report and review of the literature. Cureus. 2022;14:E24557.
  9. Porro AM, Seque CA, Ferreira MCC, et al. Pemphigus vulgaris. An Bras Dermatol. 2019;94:264-278.
  10. Bachar-Wikström E, Wikström JD. Darier disease—a multi-organ condition? Acta Derm Venereol. 2021;101:adv00430.
References
  1. Hanneken S, Rütten A, Eigelshoven S, et al. Morbus Galli-Galli. Hautarzt. 2013;64:282.
  2. Wilson NJ, Cole C, Kroboth K, et al. Mutations in POGLUT1 in Galli- Galli/Dowling-Degos disease. Br J Dermatol. 2017;176:270-274.
  3. Ralser DJ, Basmanav FB, Tafazzoli A, et al. Mutations in γ-secretase subunit–encoding PSENEN underlie Dowling-Degos disease associated with acne inversa. J Clin Invest. 2017;127:1485-1490.
  4. Desai CA, Virmani N, Sakhiya J, et al. An uncommon presentation of Galli-Galli disease. Indian J Dermatol Venereol Leprol. 2016; 82:720-723.
  5. Joshi TP, Shaver S, Tschen J. Exacerbation of Galli-Galli disease following dialysis treatment: a case report and review of aggravating factors. Cureus. 2021;13:E15401.
  6. Muller CS, Pfohler C, Tilgen W. Changing a concept—controversy on the confusion spectrum of the reticulate pigmented disorders of the skin. J Cutan Pathol. 2008;36:44-48.
  7. Dai Y, Yu L, Wang Y, et al. Case report: a case of Hailey-Hailey disease mimicking condyloma acuminatum and a novel splice-site mutation of ATP2C1 gene. Front Genet. 2021;12:777630.
  8. Banjar TA, Abdulwahab RA, Al Hawsawi KA. Confluent and reticulated papillomatosis of Gougerot and Carteaud: a case report and review of the literature. Cureus. 2022;14:E24557.
  9. Porro AM, Seque CA, Ferreira MCC, et al. Pemphigus vulgaris. An Bras Dermatol. 2019;94:264-278.
  10. Bachar-Wikström E, Wikström JD. Darier disease—a multi-organ condition? Acta Derm Venereol. 2021;101:adv00430.
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A 37-year-old woman presented with multiple hyperkeratotic small papules in the axillae and groin of 1 year’s duration. She reported pruritus and occasional sleep disruption. Subtle background reticulated hyperpigmentation was present. The patient reported that she had a great uncle with similar findings.

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Data Trends 2023: Respiratory Illnesses

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  1. Hines SE et al. Respir Med. 2022;202:106963. doi:10.1016/j.rmed.2022.106963
  2. Dursa EK et al. Am J Ind Med. 2020;63(11):980-987. doi:10.1002/ajim.23172
  3. Bamonti PM et al. Int J Chron Obstruct Pulmon Dis. 2022;17:1269-1283. doi:10.2147/COPD.S339323
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  2. Dursa EK et al. Am J Ind Med. 2020;63(11):980-987. doi:10.1002/ajim.23172
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Studies of Gulf War-era and post-9/11 veterans have confirmed that factors like deployment and blast exposure put these individuals at a higher risk for developing respiratory illnesses like COPD and asthma compared with their peers.1,2 The prevalence of COPD is expected to increase as these veterans age, and understanding their related physiological, physical, and psychological health outcomes will become increasingly critical.3 Research conducted within the VHA has played an integral role in improving outcomes in veterans with COPD, and will continue to do so in the years ahead.

 

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9. Frayne SM et al. Sourcebook: Women Veterans in the Veterans Health Administration. Volume 4: Longitudinal Trends in Sociodemographics, Utilization, Health Profile, and Geographic Distribution. Women’s Health Evaluation Initiative, Women’s Health Services, Veterans Health Administration. Published 2018. Accessed May 5, 2023. https://www.womenshealth.va.gov/WOMENSHEALTH/materials-and-resources/publications-and-reports.asp

10. Katon J et al. J Womens Health (Larchmt). 2014;23(10):792-800. doi:10.1089/jwh.2013.4681 

11. Day MA et al. Am J Orthopsychiatry. 2023;93(1):41-49. doi:10.1037/ort0000654

12. Shaw JG et al. Health Serv Res. 2018;53(suppl 3):5260-5284. doi:10.1111/1475-6773.13041

13. Shaw JG et al. Obstet Gynecol. 2014;124(6):1111-1119. doi:10.1097/AOG.0000000000000542

14. Shaw JG et al. Paediatr Perinat Epidemiol. 2017;31(3):185-194. doi:10.1111/ppe.12349

15. Kroll-Desrosiers A et al. J Gen Intern Med. 2022;37(suppl 3):762-769. doi:10.1007/s11606-022-07573-7

16. Creech SK et al. Depress Anxiety. 2022;39(3):201-210. doi:10.1002/da.23218
17. 
US Department of Defense. Department of Defense Releases Annual Demographics Report — Upward Trend in Number of Women Serving Continues. Published December 14, 2022. Accessed June 12, 2023. https://www.defense.gov/News/Releases/Release/Article/3246268/department-of-defense-releases-annual-demographics-report-upward-trend-in-numbe/

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9. Frayne SM et al. Sourcebook: Women Veterans in the Veterans Health Administration. Volume 4: Longitudinal Trends in Sociodemographics, Utilization, Health Profile, and Geographic Distribution. Women’s Health Evaluation Initiative, Women’s Health Services, Veterans Health Administration. Published 2018. Accessed May 5, 2023. https://www.womenshealth.va.gov/WOMENSHEALTH/materials-and-resources/publications-and-reports.asp

10. Katon J et al. J Womens Health (Larchmt). 2014;23(10):792-800. doi:10.1089/jwh.2013.4681 

11. Day MA et al. Am J Orthopsychiatry. 2023;93(1):41-49. doi:10.1037/ort0000654

12. Shaw JG et al. Health Serv Res. 2018;53(suppl 3):5260-5284. doi:10.1111/1475-6773.13041

13. Shaw JG et al. Obstet Gynecol. 2014;124(6):1111-1119. doi:10.1097/AOG.0000000000000542

14. Shaw JG et al. Paediatr Perinat Epidemiol. 2017;31(3):185-194. doi:10.1111/ppe.12349

15. Kroll-Desrosiers A et al. J Gen Intern Med. 2022;37(suppl 3):762-769. doi:10.1007/s11606-022-07573-7

16. Creech SK et al. Depress Anxiety. 2022;39(3):201-210. doi:10.1002/da.23218
17. 
US Department of Defense. Department of Defense Releases Annual Demographics Report — Upward Trend in Number of Women Serving Continues. Published December 14, 2022. Accessed June 12, 2023. https://www.defense.gov/News/Releases/Release/Article/3246268/department-of-defense-releases-annual-demographics-report-upward-trend-in-numbe/

References

9. Frayne SM et al. Sourcebook: Women Veterans in the Veterans Health Administration. Volume 4: Longitudinal Trends in Sociodemographics, Utilization, Health Profile, and Geographic Distribution. Women’s Health Evaluation Initiative, Women’s Health Services, Veterans Health Administration. Published 2018. Accessed May 5, 2023. https://www.womenshealth.va.gov/WOMENSHEALTH/materials-and-resources/publications-and-reports.asp

10. Katon J et al. J Womens Health (Larchmt). 2014;23(10):792-800. doi:10.1089/jwh.2013.4681 

11. Day MA et al. Am J Orthopsychiatry. 2023;93(1):41-49. doi:10.1037/ort0000654

12. Shaw JG et al. Health Serv Res. 2018;53(suppl 3):5260-5284. doi:10.1111/1475-6773.13041

13. Shaw JG et al. Obstet Gynecol. 2014;124(6):1111-1119. doi:10.1097/AOG.0000000000000542

14. Shaw JG et al. Paediatr Perinat Epidemiol. 2017;31(3):185-194. doi:10.1111/ppe.12349

15. Kroll-Desrosiers A et al. J Gen Intern Med. 2022;37(suppl 3):762-769. doi:10.1007/s11606-022-07573-7

16. Creech SK et al. Depress Anxiety. 2022;39(3):201-210. doi:10.1002/da.23218
17. 
US Department of Defense. Department of Defense Releases Annual Demographics Report — Upward Trend in Number of Women Serving Continues. Published December 14, 2022. Accessed June 12, 2023. https://www.defense.gov/News/Releases/Release/Article/3246268/department-of-defense-releases-annual-demographics-report-upward-trend-in-numbe/

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The number of pregnant veterans using VHA maternity care coverage increased > 14-fold between 2000 and 2015,and a recent survey of female active-duty service members found that > 40% have been pregnant since joining the military.17 Studies have shown that veterans treated at VHA facilities have elevated rates of pregnancy complications, such as gestational diabetes and hypertensive disorder.Active-duty service members have  reported overt experiences of stigma, harassment, and bias related to being pregnant within the work environment, contributing to negative perceptions of their pregnancy experience.10

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References

29. Touma DA et al. Mil Med. 2022;usac180. doi:10.1093/milmed/usac180
30. Flatt RE et al. Eat Behav. 2021;43:101562. doi:10.1016/j.eatbeh.2021.101562
31. Masheb RM et al. Int J Eat Disord. 2021;54(7):1171-1180. doi:10.1002/eat.23501
32. Masheb RM et al. Eat Weight Disord. 2019;24(6):1063-1070. doi:10.1007/s40519-019-00766-w
33. Etuk R et al. Mil Med. 2022;187(3-4):297-303. doi:10.1093/milmed/usab533
34. Serier KN et al. Int J Eat Disord. 2022;55(4):470-480. doi:10.1002/eat.23680

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29. Touma DA et al. Mil Med. 2022;usac180. doi:10.1093/milmed/usac180
30. Flatt RE et al. Eat Behav. 2021;43:101562. doi:10.1016/j.eatbeh.2021.101562
31. Masheb RM et al. Int J Eat Disord. 2021;54(7):1171-1180. doi:10.1002/eat.23501
32. Masheb RM et al. Eat Weight Disord. 2019;24(6):1063-1070. doi:10.1007/s40519-019-00766-w
33. Etuk R et al. Mil Med. 2022;187(3-4):297-303. doi:10.1093/milmed/usab533
34. Serier KN et al. Int J Eat Disord. 2022;55(4):470-480. doi:10.1002/eat.23680

References

29. Touma DA et al. Mil Med. 2022;usac180. doi:10.1093/milmed/usac180
30. Flatt RE et al. Eat Behav. 2021;43:101562. doi:10.1016/j.eatbeh.2021.101562
31. Masheb RM et al. Int J Eat Disord. 2021;54(7):1171-1180. doi:10.1002/eat.23501
32. Masheb RM et al. Eat Weight Disord. 2019;24(6):1063-1070. doi:10.1007/s40519-019-00766-w
33. Etuk R et al. Mil Med. 2022;187(3-4):297-303. doi:10.1093/milmed/usab533
34. Serier KN et al. Int J Eat Disord. 2022;55(4):470-480. doi:10.1002/eat.23680

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Research focused on eating disorders in active-duty service members and veterans is expanding, with recent studies finding significantly high rates of disordered eating behaviors in these populations.29,30 Bulimia nervosa and binge eating disorder are some of the most common among veterans, with increased diuretic use and excessive exercise compared with civilians.30,31 Pressure to meet certain weight requirements during active duty has a large impact on this issue, with many service members reporting disordered behaviors used to make weight.32 Future research should investigate the effect of military-related trauma on the development of eating disorders.29

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References
  1. US Department of Veterans Affairs. Nutrition and food services. Diabetes information. Updated December 1, 2022. Accessed April 14, 2023. https://www.nutrition.va.gov/Diabetes.asp
  2. Avramovic S et al. BMJ Open. 2020;10(12):e039489. doi:10.1136/bmjopen-2020-039489
  3. Adhikari S et al. BMC Health Serv Res. 2023;23(1):41. doi:10.1186/s12913-023-09057-8
  4. Zhou P et al. J Diabetes Metab Disord. 2022;21(1):759-768. doi:10.1007/s40200-022-01049-5
  5. Lamprea-Montealegre JA et al. JAMA. 2022;328(9):861-871. doi:10.1001/jama.2022.13885
  6. Fairman KA, Buckley K. Health Psychol. 2021;40(1):1-10. doi:10.1037/hea0000889
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  1. US Department of Veterans Affairs. Nutrition and food services. Diabetes information. Updated December 1, 2022. Accessed April 14, 2023. https://www.nutrition.va.gov/Diabetes.asp
  2. Avramovic S et al. BMJ Open. 2020;10(12):e039489. doi:10.1136/bmjopen-2020-039489
  3. Adhikari S et al. BMC Health Serv Res. 2023;23(1):41. doi:10.1186/s12913-023-09057-8
  4. Zhou P et al. J Diabetes Metab Disord. 2022;21(1):759-768. doi:10.1007/s40200-022-01049-5
  5. Lamprea-Montealegre JA et al. JAMA. 2022;328(9):861-871. doi:10.1001/jama.2022.13885
  6. Fairman KA, Buckley K. Health Psychol. 2021;40(1):1-10. doi:10.1037/hea0000889
References
  1. US Department of Veterans Affairs. Nutrition and food services. Diabetes information. Updated December 1, 2022. Accessed April 14, 2023. https://www.nutrition.va.gov/Diabetes.asp
  2. Avramovic S et al. BMJ Open. 2020;10(12):e039489. doi:10.1136/bmjopen-2020-039489
  3. Adhikari S et al. BMC Health Serv Res. 2023;23(1):41. doi:10.1186/s12913-023-09057-8
  4. Zhou P et al. J Diabetes Metab Disord. 2022;21(1):759-768. doi:10.1007/s40200-022-01049-5
  5. Lamprea-Montealegre JA et al. JAMA. 2022;328(9):861-871. doi:10.1001/jama.2022.13885
  6. Fairman KA, Buckley K. Health Psychol. 2021;40(1):1-10. doi:10.1037/hea0000889
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It is estimated that one-quarter of the 8 million veterans in VHA care have some form of diabetes, with another 3 million having prediabetes.1,2 Higher rates of obesity, older age, and lower socioeconomic status compared with the general public are contributing factors.2 As the long-term impact of the COVID-19 pandemic continues to be studied, it appears that HbA1c testing, prescription fills, and other outpatient care have all returned to prepandemic levels within the VHA, although recent data have revealed adverse outcomes in veterans with diabetic macular edema (DME) who delayed their eyecare appointments in 2020.3,4 As with many areas of health care, some gaps in treatment remain for different racial and ethnic groups that must be addressed to optimize outcomes for all patients.5

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  1. Howard JT et al. JAMA Netw Open. 2022;5(2):e2148150. doi:10.1001/jamanetworkopen.2021.48150
  2. Cogan AM et al. PM R. 2020;12(3):301-314. doi:10.1002/pmrj.12237
  3. Stewart IJ et al. JAMA Neurol. 2022;79(11):1122-1129. doi:10.1001/jamaneurol.2022.2682
  4. Leng Y et al. Neurology. 2021;96(13):e1792-e1799. doi:10.1212/WNL.0000000000011656
  5. Winkler SL et al. Optom Vis Sci. 2022;99(1):3-8. doi:10.1097/OPX.0000000000001824
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  1. Howard JT et al. JAMA Netw Open. 2022;5(2):e2148150. doi:10.1001/jamanetworkopen.2021.48150
  2. Cogan AM et al. PM R. 2020;12(3):301-314. doi:10.1002/pmrj.12237
  3. Stewart IJ et al. JAMA Neurol. 2022;79(11):1122-1129. doi:10.1001/jamaneurol.2022.2682
  4. Leng Y et al. Neurology. 2021;96(13):e1792-e1799. doi:10.1212/WNL.0000000000011656
  5. Winkler SL et al. Optom Vis Sci. 2022;99(1):3-8. doi:10.1097/OPX.0000000000001824
References
  1. Howard JT et al. JAMA Netw Open. 2022;5(2):e2148150. doi:10.1001/jamanetworkopen.2021.48150
  2. Cogan AM et al. PM R. 2020;12(3):301-314. doi:10.1002/pmrj.12237
  3. Stewart IJ et al. JAMA Neurol. 2022;79(11):1122-1129. doi:10.1001/jamaneurol.2022.2682
  4. Leng Y et al. Neurology. 2021;96(13):e1792-e1799. doi:10.1212/WNL.0000000000011656
  5. Winkler SL et al. Optom Vis Sci. 2022;99(1):3-8. doi:10.1097/OPX.0000000000001824
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TBIs are a neurologic event of concern for veterans, with many high-risk activities involved in military service. Post-9/11 veterans with TBI demonstrate a higher adjusted all-cause mortality rate when compared with the US population and veterans without TBI.1 Sex differences in TBI outcomes also exist, particularly within the frequency of mental health comorbidities.2 Other post-TBI conditions, including cardiovascular disease, sleep disorders, and ocular dysfunction, are prevalent as well.3-5

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Data Trends 2023: Opioid Use Disorder

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7. Bennett AS et al. Ann Med. 2022;54(1):1826-1838. doi:10.1080/07853890.2022.2092896
8. Finlay AK et al. Am J Prev Med. 2022;62(1):e29-e37. doi:10.1016/j.amepre.2021.06.014
9. Peltier MR et al. J Dual Diagn. 2021;17(2):124-134. doi:10.1080/15504263.2021.1904162
10. Beckman KL et al. Am J Prev Med. 2022;62(3):377-386. doi:10.1016/j.amepre.2021.08.020
11. Boyer TL et al. Am J Prev Med. 2022;63(2):168-177. doi:10.1016/j.amepre.2022.02.011
12. Jasuja GK et al. Med Care. 2021;59(suppl 2):S165-S169. doi:10.1097/MLR.0000000000001437
13. US Department of Veterans Affairs, Office of Public and Intergovernmental Affairs. VA’s Rapid Naloxone Initiative recognized in fight against opioid overdose deaths. Published June 8, 2021. Accessed April 21, 2023. https://www.va.gov/opa/pressrel/pressrelease.cfm?id=5679 
14. Chen EF, et. al. Fed Pract. 2022;39(3):136-141. doi:10.12788/fp.0236

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7. Bennett AS et al. Ann Med. 2022;54(1):1826-1838. doi:10.1080/07853890.2022.2092896
8. Finlay AK et al. Am J Prev Med. 2022;62(1):e29-e37. doi:10.1016/j.amepre.2021.06.014
9. Peltier MR et al. J Dual Diagn. 2021;17(2):124-134. doi:10.1080/15504263.2021.1904162
10. Beckman KL et al. Am J Prev Med. 2022;62(3):377-386. doi:10.1016/j.amepre.2021.08.020
11. Boyer TL et al. Am J Prev Med. 2022;63(2):168-177. doi:10.1016/j.amepre.2022.02.011
12. Jasuja GK et al. Med Care. 2021;59(suppl 2):S165-S169. doi:10.1097/MLR.0000000000001437
13. US Department of Veterans Affairs, Office of Public and Intergovernmental Affairs. VA’s Rapid Naloxone Initiative recognized in fight against opioid overdose deaths. Published June 8, 2021. Accessed April 21, 2023. https://www.va.gov/opa/pressrel/pressrelease.cfm?id=5679 
14. Chen EF, et. al. Fed Pract. 2022;39(3):136-141. doi:10.12788/fp.0236

References

7. Bennett AS et al. Ann Med. 2022;54(1):1826-1838. doi:10.1080/07853890.2022.2092896
8. Finlay AK et al. Am J Prev Med. 2022;62(1):e29-e37. doi:10.1016/j.amepre.2021.06.014
9. Peltier MR et al. J Dual Diagn. 2021;17(2):124-134. doi:10.1080/15504263.2021.1904162
10. Beckman KL et al. Am J Prev Med. 2022;62(3):377-386. doi:10.1016/j.amepre.2021.08.020
11. Boyer TL et al. Am J Prev Med. 2022;63(2):168-177. doi:10.1016/j.amepre.2022.02.011
12. Jasuja GK et al. Med Care. 2021;59(suppl 2):S165-S169. doi:10.1097/MLR.0000000000001437
13. US Department of Veterans Affairs, Office of Public and Intergovernmental Affairs. VA’s Rapid Naloxone Initiative recognized in fight against opioid overdose deaths. Published June 8, 2021. Accessed April 21, 2023. https://www.va.gov/opa/pressrel/pressrelease.cfm?id=5679 
14. Chen EF, et. al. Fed Pract. 2022;39(3):136-141. doi:10.12788/fp.0236

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The rate of opioid overdose mortality in veterans increased rapidly over the last decade.7 Several characteristics have been shown to affect opioid-related mortality in veterans—factors such as legal involvement, military sexual trauma, gender identity, and homelessness status.8-12 While widespread initiatives are working to address these issues—with some VA programs demonstrating successful and significant reductions in opioid overdoses13—there is still much work to be done.

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1. Moradi Y et al. BMC Psychiatry. 2021;21(1):510. doi:10.1186/s12888-021-03526-2
2. Ziobrowski HN et al. J Affect Disord. 2021;290:227-236. doi:10.1016/j.jad.2021.04.033
3. Szukis H et al. Curr Med Res Opin. 2021;37(8):1393-1401. doi:10.1080/03007995.2021.1918073
4. Levey DF et al. Nat Neurosci. 2021;24(7):954-963. doi:10.1038/s41593-021-00860-2
5. Madore MR et al. J Affect Disord. 2022;297:671-678. doi:10.1016/j.jad.2021.10.025
6. Cheng CM et al. Adv Exp Med Biol. 2021;1305:333-349. doi:10.1007/978-981-33-6044-0_18

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1. Moradi Y et al. BMC Psychiatry. 2021;21(1):510. doi:10.1186/s12888-021-03526-2
2. Ziobrowski HN et al. J Affect Disord. 2021;290:227-236. doi:10.1016/j.jad.2021.04.033
3. Szukis H et al. Curr Med Res Opin. 2021;37(8):1393-1401. doi:10.1080/03007995.2021.1918073
4. Levey DF et al. Nat Neurosci. 2021;24(7):954-963. doi:10.1038/s41593-021-00860-2
5. Madore MR et al. J Affect Disord. 2022;297:671-678. doi:10.1016/j.jad.2021.10.025
6. Cheng CM et al. Adv Exp Med Biol. 2021;1305:333-349. doi:10.1007/978-981-33-6044-0_18

References

1. Moradi Y et al. BMC Psychiatry. 2021;21(1):510. doi:10.1186/s12888-021-03526-2
2. Ziobrowski HN et al. J Affect Disord. 2021;290:227-236. doi:10.1016/j.jad.2021.04.033
3. Szukis H et al. Curr Med Res Opin. 2021;37(8):1393-1401. doi:10.1080/03007995.2021.1918073
4. Levey DF et al. Nat Neurosci. 2021;24(7):954-963. doi:10.1038/s41593-021-00860-2
5. Madore MR et al. J Affect Disord. 2022;297:671-678. doi:10.1016/j.jad.2021.10.025
6. Cheng CM et al. Adv Exp Med Biol. 2021;1305:333-349. doi:10.1007/978-981-33-6044-0_18

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Depression affects nearly a quarter of active-duty service members and veterans worldwide.Common comorbidities in patients with depression include generalized anxiety disorder, PTSD, and panic disorder.2 Additionally, depression—and especially treatment-resistant depression (TRD)—has a high economic burden, with health care costs reaching nearly $20,000 per patient per year.3 New research aims to identify genes associated with depression as well as treatments that may be effective in veterans.3-5

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24. Nichter B et al. Psychol Med. 2022;1-11. doi:10.1017/S0033291722000617
25. Lin D et al. BMC Psychiatry. 2022;22(1):458. doi:10.1186/s12888-022-04022-x
26. Jutkowitz E et al. R I Med J (2013). 2021;104(4):20-25. Published 2021 May 3.
27. Holliday R et al. Fed Pract. 2022;39(1):8-11. doi:10.12788/fp.0216
28. Koh KA et al. Am J Prev Med. 2022;63(1):13-23. doi:10.1016/j.amepre.2021.12.028

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24. Nichter B et al. Psychol Med. 2022;1-11. doi:10.1017/S0033291722000617
25. Lin D et al. BMC Psychiatry. 2022;22(1):458. doi:10.1186/s12888-022-04022-x
26. Jutkowitz E et al. R I Med J (2013). 2021;104(4):20-25. Published 2021 May 3.
27. Holliday R et al. Fed Pract. 2022;39(1):8-11. doi:10.12788/fp.0216
28. Koh KA et al. Am J Prev Med. 2022;63(1):13-23. doi:10.1016/j.amepre.2021.12.028

References

24. Nichter B et al. Psychol Med. 2022;1-11. doi:10.1017/S0033291722000617
25. Lin D et al. BMC Psychiatry. 2022;22(1):458. doi:10.1186/s12888-022-04022-x
26. Jutkowitz E et al. R I Med J (2013). 2021;104(4):20-25. Published 2021 May 3.
27. Holliday R et al. Fed Pract. 2022;39(1):8-11. doi:10.12788/fp.0216
28. Koh KA et al. Am J Prev Med. 2022;63(1):13-23. doi:10.1016/j.amepre.2021.12.028

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Veterans have a higher lifetime prevalence and many risk factors that increase their odds of homelessness compared with the general population.24 Some of these risk factors include adverse childhood experiences, depression, PTSD, and lower educational attainment.24 Schizophrenia and neurodegenerative disorders have also been associated with homelessness in veterans.25,26 VA programs focused on case management services and temporary housing are working to lessen the burden of homelessness.27

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