Holly Peek, MD, MPH

As technology continues to expand exponentially, so does our potential to harness these technological capabilities to expand the field of psychiatry. At Psychiatric Times this year, we highlighted a range of topics on these advancements.The following slides are summaries of several of our popular articles. These topics are based on the development of internet and mobile technologies for mental health, a major area of development that has become a popular, and at times controversial, conversation.As you scroll through the slides, please read in the captions for descriptions and links to articles.Â 

Slideshows

As technology continues to expand exponentially, so does our potential to harness these technological capabilities to expand the field of psychiatry. At Psychiatric Times this year, we highlighted a range of topics on these advancements.

Technology in Psychiatry: Year in Review

[[{"type":"media","view_mode":"media_crop","fid":"33185","attributes":{"alt":"Social Media and Mobile Apps for Mental Health","class":"media-image media-image-right","height":"120","id":"media_crop_1184532296321","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3494","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image","width":"164"}}]]It is nearly impossible to walk down the street, ride the subway, go to a coffee shop, or even have family time at home without being surrounded by people deeply engrossed in the digital worlds of their smartphones. Being digitally wired has become a large part of our everyday lives. Whether we engage in social media, listen to music, watch videos, text with friends, or read the news, there is no doubt that many of us are socially dependent on these devices. In fact, research has shown that not only do we have feelings of anxiety when separated from our smartphones, but we also have negative cognitive and physiological responses to that stress.

 For better or worse, our inseparability from our smartphones will continue to deepen as the technological capabilities of these devices expand and evolve.

But what if we were able to harness the immense power of our digital connections to create tools that can potentially make our lives happier and healthier? That is exactly what is in development.

The growth of health and fitness smartphone apps has been exponential. Research by Flurry Analytics found that in 2013, the overall mobile app industry grew 115% in terms of average daily use.

In the first half of 2014, health and fitness apps specifically saw a 62% increase in use, an 87% faster growth than the rest of the mobile app industry, which is itself growing at an exponential rate. There are over 6000 health and fitness mobile apps available, with features such as activity monitoring, food diaries, and calorie counting.

More recently, apps are being developed specifically to monitor behavioral health patterns. The use of smartphone technology allows for collection of sensor data of an individual’s behavior to identify behavioral trends. For instance, Ginger.io uses sensor data as well as self- reported information collected through the phone to help mental health professionals identify problematic behaviors that may indicate the need for additional support.

The app can monitor movement and communication patterns to determine whether someone has been isolating from others, decreasing activity, or having changes in mood, all of which could be indicative of depression. In a series of studies, research from the MIT Media Lab supports the use of this type of data collection and analysis by demonstrating relationships between mood, sleep, and sociability and showing how these data can be collected through smartphone sensors to help monitor symptoms of depression.

Mental health professionals using the Ginger.io app can invite patients to install the app on their smartphones. The app will monitor and analyze both the patient’s sensor and self-report data. Whether the patient has a low score on a mood survey or a concerning change in behavior patterns, Ginger.io will notify the mental health professional when an intervention may be warranted. For instance, let’s say a patient has not been sleeping well and decides to stay home from work for several days. The patient’s decreased mobility triggers an alert to his mental health professional that the patient’s mood is declining, based on analytics of a population model that shows that mobility is inversely proportional to mood. The mental health professional can then reach out to the patient via phone to check in and provide appropriate support.

The Ginger.io app is currently used by 30 medical centers, including Kaiser Permanente and the University of California, San Francisco. Research and development of other apps are also in progress, with a $2.42 million grant from the NIH given to researchers at the Harvard School of Public Health to develop an app that will analyze factors such as unlocking and locking phones to determine sleep patterns.

The benefit of using smartphone apps to monitor behavior includes the nature of the continuous, passive collection of data. Not relying completely on self-report will lead to more accuracy of information. Also, using this already ubiquitous device for data collection will not serve as an inconvenience to the user. Physicians will have the benefit of collecting real-time information so they may efficiently serve their patients in need.

However, some patients and health care professionals have expressed concerns about privacy information, questioning how this information can be used in the future by health insurance providers. Furthermore, unless the algorithms for the notification of health care professionals have an ideal sensitivity and specificity, physicians could potentially receive a number of false-positive notifications, ultimately leading to increased workload and costs. Although the technology has great potential to identify those at highest risk while providing more accurate and comprehensive patient care, concerns about privacy as well as effects on workload remain to be seen.

Surveillance on personal smartphones is not the only technology being used to collect data on behavioral health. Infodemiology is a new field of study in which Internet and social media platforms are used to explore distribution and determinants of health information.

 For instance, information gathering from user-generated data on Twitter has allowed researchers to accurately measure the spread of the flu in a population, both in the US and abroad.

Traditionally, the CDC has relied on outpatient reporting and test results provided by laboratories to confirm flu outbreaks, techniques that take a considerable amount of time with information that is 2 weeks old by the time it is released. However, using infodemiology tools such as Google Flu Trends, created in collaboration with the CDC, Internet search terms are used to map flu activity relatively quickly.

In addition, computer scientists at Johns Hopkins University have created methods to filter public Twitter posts to uncover patterns of various health issues, such as the flu, cancer, allergies, and depression. This information can further be used to track trends more quickly than traditional epidemiological methods.

Harnessing the power of infodemiology with the widespread use of social media, the Collaborative Research on Addiction at NIH (CRAN) has recently awarded $11 million to support studies that will help prevent and treat substance use and addiction.

 Specifically, funded studies use social media platforms as tools to gain insight into patterns of substance use, risk factors, and behaviors associated with substance use. These insights can be further used to enhance screening, prevention, and treatment. Supported studies range from analyzing and monitoring cannabis and synthetic cannabinoid use to interventions to reduce prescription drug abuse, all using social media.

Researchers are also developing methods to predict depression in individuals on the basis of social media posts. In a 2013 study, Microsoft Research recruited volunteers to allow access to their Twitter accounts and to take a screening test for depression.

 Those with moderate to severe depression were less socially active on Twitter, posted more negative messages, and were more concerned with health and relationships than those volunteers who did not screen positive for depression. Researchers then developed an algorithm to predict those vulnerable for depression on the basis of their Twitter posts, which was shown to be 70% predictive within the study group.

This technology is not without controversy. Some nonprofit and research groups have developed their own software to monitor, predict, and intervene when individuals are identified to be at risk for mental health issues, such as suicide. A nonprofit suicide prevention organization in the UK, The Samaritan Group, recently came under fire after introducing a Web app called Samaritans Radar that alerts users whenever someone they are following on Twitter posts phrases that may be concerning for suicide, such as “I hate myself” or “tired of being alone.”â©

After 1 week, 4000 people had signed up for the service, following a total of 1.9 million Twitter accounts, with no notification sent to the accounts that were being monitored. After much public outcry, the app was deactivated. Some experts express concern about allowing the untrained public to monitor social media accounts using algorithms that may or may not be validated, potentially unwittingly and inaccurately labeling millions of people with mental health disorders.

This introduces many ethical dilemmas. If an individual is identified to be at risk for suicide or any mental health disorder through the use of a population-based algorithm on social media, how are laypersons or mental health professionals to intervene? What are the ethical boundaries and limitations of an intervention? Who should have access to such tools? How can this information be used in the future by insurance companies and employers? Although this new technology has tremendous potential for the creation of monitoring and intervention tools, it is still too early in development to determine how they can be appropriately used.

Technology using smartphone apps and social media to help monitor, identify, and treat mental illness is evolving, with promising results that can potentially change how we practice psychiatry in the future. Although this technology is currently in the early stages of development and fraught with ethical concerns and dilemmas, it is important that we continue to support these endeavors to continually improve how we approach mental health at both a population and an individual level.

 Clayton RB, Leshner G, Almond A. The extended iSelf: the impact of iPhone separation on cognition, emotion, and physiology. 

http://onlinelibrary.wiley.com/doi/10.1111/jcc4.12109/full

 Khalaf S. Health and fitness apps finally take off, fueled by fitness fanatics. 

. June 19, 2014. http://www.flurry.com/blog/flurry-insights/health-and-fitness-apps-finally-take-fueled-fitness- fanatics. Accessed February 18, 2015.

 Ginger.io. Big data, better health. Smarter care starts with your smartphone. https://ginger.io. Accessed February 18, 2015.

 Moturu ST, Khayal I, Aharony N, et al. Using social sensing to understand the links between sleep, mood, and sociability. In: Proceedings of the IEEE International Conference on Social Computing (SocialCom 2011); September 2011; Cambridge, MA. http://hd.media.mit.edu/tech-reports/TR-670.pdf. Accessed February 18, 2015.

 Moturu ST, Khayal I, Aharony N, et al. Sleep, mood and sociability in a healthy population. 

 Walker J. Can a smart phone tell if you’re depressed? 

. January 5, 2015. http://www.wsj.com/articles/can-a-smartphone-tell-if-youre-depressed-1420499238. Accessed February 18, 2015.

 Hanson CL, Cannon B, Burton S, Giraud-Carrier C. An exploration of social circles and prescription drug abuse through twitter.

. 2013; 15:e189. September 6, 2013. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3785991. Accessed February 18, 2015.

 Santos JC, Matos S. Analysing Twitter and web queries for flu trend prediction. 

. 2014;11(suppl 1):S6. http://www.tbiomed.com/content/11/S1/S6. Accessed February 18, 2015.

 Google Flu Trends. Explore flu trends-United States. https://www.google.org/flutrends/us/#US. Accessed February 18, 2015.

A Model for Mining Public Health Topics From Twitter

. Technical Report. Johns Hopkins University; 2011. http://www.cs.jhu.edu/~mpaul/files/2011.tech.twitter_health.pdf. Accessed February 18, 2015.

 National Institutes of Health. Using social media to better understand, prevent, and treat substance abuse. October 17, 2014. 

http://www.nih.gov/news/health/oct2014/nida-17.htm

 De Choudhury M, Gamon M, Counts S, Horvitz E. Predicting depression via social media. Microsoft Research. Association for the Advancement of Artificial Intelligence. 2013. http://research.microsoft.com/pubs/192721/icwsm_13.pdf. Accessed February 18, 2015.

 Singer N. Risks in using social media to spot signs of mental distress. 

. Decem-ber 26, 2014. http://www.nytimes.com/2014/12/ 27/technology/risks-in-using-social-posts-to- spot-signs-of-distress.html. Accessed February 18, 2015.

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What if we were able to harness the immense power of our digital connections to create tools that can potentially make our lives happier and healthier? 

Harnessing Social Media and Mobile Apps for Mental Health

The selfie phenomenon is a pervasive part of our culture: “selfie” was even Oxford dictionary’s word of the year in 2013. Because of the widespread use of selfies by young people in social media and digital communication, it is important to examine the psychology behind the selfie as well as ways mental health professionals can talk to adolescents and their parents about these issues.

Selfies are often seen as a representation of the narcissistic stereotype of the millennial generation or even as an indicator of low self-esteem, social dependence, or attention-seeking behavior. However, in the context of the digital age, in which young people are immersed in technology and connecting with one another via texting or social media, the selfie is perhaps not always negative.

As a way to connect, selfies are often used to share important experiences and to express feelings at a particular time. It is not a new phenomenon for people to use photographs to document experiences or events. However, with smartphone capabilities, it is now possible to capture a moment spontaneously and to express mood without having to wave down a passerby to take a photo. These expressive images can immediately be shared with social circles via social media. A selfie can be more intimate than a staged photograph because it captures a moment in time that is meant to be shared with others. Many adolescents are trying to develop their sense of identity, experimenting with different looks and experiences, and deciding how they feel while sharing with their social circle. Selfies can be an important part of development within the digital age.

Social networking itself has the potential to increase self-esteem and well-being in adolescents because they receive positive feedback on their social network profile. It also gives an opportunity for affiliation, self-expression, and control over self-presentation.

 Since people control how they are portrayed in their social network profile, they are able to increase their self-esteem momentarily while presenting a positive self-view to others.

 Social networking can enhance a person’s self-esteem and positively affect his or her well-being, particularly when he or she is focused on strong ties to other people while browsing social network pages.

Not all selfies and social media use are benign and without consequences. In fact, studies have shown that increased social media use can actually decrease life satisfaction. Researchers from the University of Michigan found that the more time spent on Facebook, the worse people felt. Researchers also found that more “direct” contact with other people, such as face-to-face interactions, led people to feel better about themselves over time.

Researchers from Humboldt University, Berlin, found that one-third of Facebook users in their study felt worse after visiting the site, which sparked frustration, jealousy, and decreased life satisfaction-particularly when viewing others’ vacation and holiday photos. Those most vulnerable to these negative feelings were people who did not post or engage in any interpersonal Facebook interactions themselves, but who used it as an information source by browsing newsfeeds and others’ profiles.

Perhaps a key point to healthy selfie and social media use is establishing and focusing on the digital interactions and connections made with others, rather than passively browsing others’ digital lives. Whether social media use has a positive or negative effect on self-esteem or life satisfaction can be debated. However, a clear danger often comes with the private texting of nude or sexually charged selfies, often referred to as “sexting.” When adolescents are caught sending nude selfies to one another, the issue of child pornography along with subsequent legal implications arises.

, “Why Kids Sext,” demonstrates, sexting is prevalent in high school culture.5 A 2009 Cox Communications study showed that 20% of teens reported having “participated in sexting” and a study by Pew Internet and American Life Project found that 15% of teens had received “nude or sexually suggestive” photographs on their cell phones.

So why do teens sext? In a study of 617 college freshman, 30% reported sending a nude picture at some point during high school and 45% reported receiving one. The most common reason for sexting was because a date or a boyfriend or girlfriend wanted the picture: the hope was that sexting would attract that person. However, the most concerning motivation behind sexting was pressure or coercion. When a sext was sent under pressure, it was more likely to have a negative emotional impact on the person than if the sext was sent voluntarily. These pressured students were also more likely to have a history of excessive anxiety or dating violence. Luckily, 79% of the sexters reported that the picture itself caused no social or legal problems for them after they sent it.

The cultural phenomenon of the selfie has taken many forms, whether in detailing events of our daily lives by sharing them on social media or sending nude or suggestive selfies through text messages. In our digital age, it is important for mental health professionals to be knowledgeable about the pervasiveness of social media use and sexting and to be able to talk about it with adolescent patients and their families. Exploring how an adolescent uses selfies, social media, and digital communication can be an important part of a mental health assessment, and can open the door for discussions about self-esteem, body image, healthy relationships, and digital safety.

Dr Peek is a Resident in the department of psychiatry and behavioral sciences at Tulane University School of Medicine in New Orleans. She reports no conflicts of interest concerning the subject matter of this article.

 Wilcox K, Stephen AT. Are close friends the enemy? Online social networks, self-esteem, and self-control. 

 Gonzales AL, Hancock JT. Mirror, mirror on my Facebook wall: effects of Facebook exposure on self-esteem. 

 Kross E, Verduyn P, Demiralp E, et al. Facebook use predicts declines in subjective well-being in young adults. PLoS One. August 2013. http://www.plosone.org/article/fetchObject.action?uri=info%3Adoi%2F10.1371%2Fjournal.pone.0069841&representation=PDF. Accessed November 12, 2014.

 Krasnova H, Wenninger H, Widjaja T, Buxmann R. Envy on Facebook: a hidden threat to users’ life satisfaction? 2013. http://warhol.wiwi.hu-berlin.de/~hkrasnova/Ongoing_Research_files/WI%202013%20Final%20Submission%20Krasnova.pdf. Accessed November 12, 2014.

. October 14, 2014. http://m.theatlantic.com/magazine/archive/2014/11/why-kids-sext/380798/?single_page=true. Accessed November 12, 2014.

Teen Online & Wireless Safety Survey: Cyberbullying, Sexting and Parental Controls

. May 2009. http://ksdresources.pbworks.com/f/2009_teen_survey_internet_and_wireless_safety%5B1%5D.pdf. Accessed November 12, 2014.

. Pew Research Center; December 15, 2009. http://www.pewinternet.org/files/old-media//Files/Reports/2009/PIP_Teens_and_Sexting.pdf. Accessed November 12, 2014.

 Englander E. Low risk associated with most teenage sexting: a study of 617 18-yearolds. In: 

. 2012. http://vc.bridgew.edu/cgi/viewcontent.cgi?article=1003&context=marc_reports. Accessed November 12, 2014.

Because of the widespread use of selfies by young people in social media and digital communication, it is important to examine the psychology behind the selfie as well as ways mental health professionals can talk to adolescents and their parents about these issues.

The Selfie in the Digital Age: From Social Media to Sexting

Psychiatry residents and early-career psychiatrists were among the first to engage in social media while in their college dorm rooms. Facebook began in 2004 as an interactive directory for college students, to share photographs and basic information. Ten years later, the site now boasts over a billion users worldwide and can include anyone 13 years or older as well as businesses, organizations, celebrities, and political figures. Although Facebook was the first popular Web site of its kind, social media now encompasses various forms of media with popular sites such as YouTube, Twitter, Instagram, Pinterest, and LinkedIn.

Along with the exploding popularity of social media over the past decade came the potential pitfalls for many young adults entering graduate schools and their early careers. Personal pictures, posts, and information have become readily available on the Internet, prompting schools, training directors, and employers to screen applicants by searching for them online before offering an interview or a job. Furthermore, it is often even more concerning that a patient may stumble across information on personal social sites. Unfortunately, as the first generation of social media users have entered their early careers, a sense of fear has swept over the online communication scene, with many of these users disengaging altogether.

However, instead of viewing social media as a potential catalyst for` a career downfall, it can be an extremely worthwhile career opportunity for psychiatrists. The current generation of residents and early-career psychiatrists have essentially been engaged in social media for longer than any other generation. This means they are more likely to know how to use the technology and are more accustomed to readily sharing their thoughts and ideas through this very public platform. Re-creating an online presence from personal to professional has several advantages.

Engaging in social media as a psychiatrist is important because our patients spend a significant amount of their time online, and this is where they receive their health information. The 

 in the US spends 32 hours a month online, with 22% of this time spent on social media sites.

 Furthermore, smartphone users average 24 minutes per day using social networking apps.

While spending this time on the Internet, users are doing a lot more than casually socializing with their peers. In fact, according to the Pew Research Center’s Internet & American Life Project, 72% of adult online users have searched the Internet for health-related information in the past year.

 has also shown that one-third of social media consumers are using it for 

, reading stories on a Web site or blog, signing up to receive alerts and e-mails, or joining a health-related group on a social networking site.

More than traditional Web sites, social media has changed the landscape of how psychiatrists can make use of the Internet. It has unlocked doors for open conversations among physicians, patients, and the general public. We have the ability to disseminate knowledge of evidence-based strategies, provide context to mental health stories in the media, and dispel myths. There are certainly people who are putting false, misleading, and potentially harmful information on the Internet. Therefore we, as mental health professionals, should use social media in a beneficial way by sharing our expertise and knowledge in the field.

Arguably, there is more stigma associated with psychiatric disorders than with any other health problems; this affects patients’ mental health outcomes and, on a larger scale, funding and resources available to us and our patients. Social media is our opportunity to give voice to the fight against stigma by educating the public about mental health.

No discussion about social media is complete without talking about maintaining professionalism online. Because social media use for physicians is a relatively new and evolving phenomenon, professional organizations such as the AMA are now creating guidelines for appropriate use. It is essential for any physician using social media to review these guidelines: 

Opinion 9.124-Professionalism in the Use of Social Media

 By following them, any trepidation about entering the social media scene can be alleviated.

Instead of avoiding social media altogether, I encourage mental health professionals to embrace this new and exponentially growing mode of communication. It is essential that we align ourselves with the public and our patients both to disseminate accurate information and to educate. Social media allows us to have this public voice more than ever before. Psychiatry residents and early-career psychiatrists certainly have an advantage in this arena in that many have been using social media for the past decade. However, digital media is not just for younger psychiatrists; medical professionals of all ages are now embracing the social media world. Learning how to use digital tools to teach patients, engage the public, and ultimately advocate for mental health is a skill worth adding to our professional repertoire.

This article was originally posted on 7/9/2014 and has since been updated.

Dr Peek is a psychiatry resident at Tulane University School of Medicine, department of psychiatry and behavioral sciences, New Orleans. Her Web site is www.psychgumbo.com and Twitter handle, @psychgumbo. She is the Digital Media in Psychiatry Section Editor for Psychiatric Times and the Media Editor for the American Journal of Psychiatry Residents Journal.

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http://www.mediabistro.com/alltwitter/online-time_b22186

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http://www.pewinternet.org/2013/01/15/health-online-2013

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http://www.pwc.com/us/en/health-industries/publications/health-care-social-media.jhtml

 Fox S, Jones S. The social life of health information. A shifting landscape. Pew Research Internet Project. June 11, 2009. 

http://www.pewinternet.org/2009/06/11/a-shifting-landscape

 American Medical Association. Opinion 9.124-Professionalism in the use of social media. 

http://www.ama-assn.org//ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion9124.page

It is essential that we psychiatrists align ourselves with the public and our patients both to disseminate accurate information and to educate. Social media allows us to have this public voice more than ever before.

Social Media: An Opportunity for Psychiatrists

The popularity of social media has brought with it an innovative way for physicians to connect with others, whether that be networking with colleagues, promoting health information, or advocating for patients. However, social media has also created professionalism and ethics concerns for the modern psychiatrist, particularly psychiatry trainees. Guidelines for ethical conduct on social media are new and developing, and were the basis for a disscussion at a workshop called “Blurred Lines: Challenges Encountered by Psychiatry Trainees in Maintaining Professionalism in the Digital Age” at the APA annual convention. Drs Jennifer Laidlaw, Kathleen Sheehan, and Adrienne Tan of the University Health Network in Toronto were the presenters.

Social media is defined as “Internet-based media and interfaces designed to connect people to each other and facilitate interaction with user-generated content.”

 in health care is clear: 72% of patients seek health information online and 20% use social media to connect with others with the same illness.

 In addition, physicians are also using social media: 87% have a personal social media account and 67% maintain a professional account.

 Social media use has become essential in modern health care for instantaneous information sharing and collaboration between health care professionals and for providing credible information and advocacy for patients and the general public.

However, with both physicians and patients using social media, situations of questionable ethical and professional conduct often arise. Thirty-five percent of physicians report receiving a “friend” request from a patient, and 16% of physicians admit they have visited a patient’s online profile.

 In a study of medical student social media use, 60% of the US medical schools under examination reported unprofessional online content posted by their medical students.

Unprofessional behavior included breaches of confidentiality, use of profanity or discriminatory language, depictions of intoxication, and sexually suggestive material.

Current guidelines by the AMA, Federation of State Medical Boards (FSMB), and a joint paper by the FSMB and American College of Physicians are evolving and often lag behind fast-growing social media presence of medical professionals.

A few important points from these guidelines:

• All content should be considered public and permanent

• Always consider patient privacy and confidentiality in social media

• Use privacy settings to safeguard personal information and content

• Maintain appropriate boundaries when interacting with patients online

• Consider keeping separate personal and professional social media accounts

• When you find unprofessional content posted by a colleague, bring it to the attention of the colleague; if it is not adequately addressed, bring it to the attention of appropriate authorities

As the use of social media becomes necessary for the online presence of medical professionals, this topic will continue to be essential for the train-ing of current and future psychiatrists.

Guidelines for Physicians When Using Social Media

http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion9124.page

http://www.fsmb.org/pdf/pub-social-media-guidelines.pdf

http://www.acponline.org/pressroom/online_medical_professionalism.htm

This article was originally posted online on 5/15/2014 and has since been updated.

Dr Peek is a psychiatry resident at Tulane University School of Medicine, Department of Psychiatry and Behavioral Sciences, New Orleans, Louisiana. Her website is 

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As the use of social media becomes necessary for the online presence of medical professionals, this topic will continue to be essential for the training of both current and future psychiatrists.

Author | Holly Peek, MD, MPH

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