Rheumatoid arthritis

Rheumatoid arthritis causes inflammation, pain, and swelling of joints. Persistent inflammation over time can damage affected joints. The severity can vary from mild to severe. Treatments include disease modifying drugs to suppress inflammation which can slow down the progression of the disease, and medication to ease pain. The earlier treatment is started, the less joint damage is likely to occur. Surgery is needed in some cases if a joint becomes badly damaged.

What is rheumatoid arthritis?

Arthritis means inflammation of joints. Rheumatoid arthritis (RA) is a common form of arthritis. About 1 in 100 people develop RA at some stage in their life. It can happen to anyone. It is not a hereditary disease. It can develop at any age, but most commonly starts between the ages of 40 and 60. It is three times more common in women than in men.

      

        

                

Understanding joints

Cross-section diagram of a normal joint (072.gif)

A joint is where two bones meet. Joints allow movement and flexibility of various parts of the body. The movement of the bones is caused by muscles which pull on tendons that are attached to bone.

Cartilage covers the end of bones. Between the cartilage of two bones that form a joint there is a small amount of thick fluid called synovial fluid. This 'lubricates' the joint which allows smooth movement between the bones.

The synovial fluid is made by the synovium. This is the tissue that surrounds the joint. The outer part of the synovium is called the capsule. This is tough, gives the joint stability, and stops the bones from moving 'out of joint'. Surrounding ligaments and muscles also help to give support and stability to joints.

What causes rheumatoid arthritis?

RA is thought to be an autoimmune disease. The immune system normally makes antibodies (small proteins) to attack bacteria, viruses, and other 'germs'. In people with autoimmune diseases, the immune system makes antibodies against tissues of the body. It is not clear why this happens. Some people have a tendency to develop autoimmune diseases. In such people, something might trigger the immune system to attack the body's own tissues. The 'trigger' is not known.

In people with RA, antibodies are formed against the synovium (the tissue that surrounds each joint). This causes inflammation in and around affected joints. Over time, the inflammation can damage the joint, the cartilage, and parts of the bone near to the joint.

Which joints are affected in rheumatoid arthritis?

The most commonly affected joints are the small joints of the fingers, thumbs, wrists, feet, and ankles. However, any joint may be affected. The knees are quite commonly affected. Less commonly the hips, shoulders, elbows, and neck are involved. It is often symmetrical. So, for example, if a joint is affected in a right arm, the same joint in the left arm is also often affected. In some people, just a few joints are affected. In others, many joints are involved.

What are the symptoms of rheumatoid arthritis?

Joint symptoms

The common main symptoms are pain and stiffness of affected joints. The stiffness is usually worse first thing in the morning, or after you have been resting. The inflammation causes swelling around the affected joints.

Other symptoms

These are known as 'extra-articular' symptoms of RA (meaning 'outside of the joints'). A variety of symptoms may occur. The cause of some of these is not fully understood.

  • Small painless lumps or 'nodules' develop in about 1 in 4 cases. These commonly occur on the skin over the elbows and forearms, but usually do no harm.
  • Inflammation around tendons may occur. This is because the tissue which covers tendons is similar to the synovium around the joints.
  • Anaemia and tiredness are common.
  • A fever, feeling unwell, weight loss, and muscle aches and pains sometimes occur.
  • In a few cases, inflammation develops in other parts of the body such as the lungs, heart, blood vessels, or eyes. This is uncommon but if it occurs can cause various symptoms and problems which are sometimes serious.

How does rheumatoid arthritis develop and progress?

In most cases the symptoms develop gradually - over several weeks or so. Typically, you may first develop some stiffness in the hands, wrists, or soles of the feet in the morning which eases by mid-day. This may come and go for a while, but then becomes regular. You may then notice some pain and swelling in the same joints. More joints such as the knees may then become affected.

In a small number of cases, less common patterns are seen. For example:

  • In some cases pain and swelling develops quickly in many joints - over a few days or so.
  • Some people have bouts of symptoms which affect several joints. Each bout lasts a few days, and then goes away. Several bouts may occur before persistent symptoms develop.
  • In some people, usually young women, the disease affects just one or two joints at first, often the knees.
  • The non-joint symptoms such as muscle pains, anaemia, weight loss, and fever are sometimes more obvious at first before joint symptoms develop.

RA can vary greatly from person to person. It is usually a chronic relapsing condition. Chronic means that it is persistent. Relapsing means that at times the disease flares-up (relapses), and at other times it settles down. There is usually no apparent reason why the inflammation may flare-up for a while, and then settle down.

Most people with RA have this pattern of flare-ups followed by better spells. In some people, months or even years may go by between flare-ups. Some damage may be done to affected joints during each flare-up. The amount of disability which develops usually depends on how much damage is done over time to the affected joints.

In a minority of cases the disease is constantly progressive, and severe joint damage and disability can develop quite quickly.

Smoking seems to be a possible factor as, on average, the severity of RA tends to be worse in smokers than non-smokers.

Joint damage

Inflammation can damage the cartilage which may become eroded or worn. The bone underneath may become thinned. The joint capsule and nearby ligaments and tissues around the joint may also become damaged. Joint damage develops gradually. Over time, it may lead to deformities. It may become difficult to use the affected joints. For example, the fingers and wrists are commonly affected, so a good grip and other tasks using the hands may become difficult.

Most people with RA develop some damage to affected joints. The amount of damage can range from mild to severe. At the outset of the disease it is difficult to predict for an individual how badly the disease will progress. However, modern treatments can often limit the progression of the disease and limit the joint damage (see below).

How is rheumatoid arthritis diagnosed?

There is no single test which clearly diagnoses early RA. When you first develop joint pains, it may be difficult for a doctor to say that you definitely have RA. This is because there are many other causes of joint pains. Blood tests can detect inflammation, characteristic antibodies, and anaemia. These may suggest that you have RA, but do not prove that you definitely have it as these blood results can be caused by other conditions.

You may have a time of uncertainty when early symptoms 'could be' RA. In time, X-rays of joints may begin to show typical erosions (early damage) and other features of RA which makes the diagnosis more certain.

Some other associated diseases and possible complications

Associated conditions

The risk of developing certain other conditions is higher in people with RA. These include: heart disease, stroke, infections (joint infections and non-joint infections), gut problems, osteoporosis (thinning of the bones), and certain cancers.

It is not clear why these conditions develop more commonly in people with RA. One possible reason is that, on average, people with RA tend to have more 'risk factors' for developing some of these conditions. For example:

  • Lack of exercise and high blood pressure are 'risk factors' for developing heart disease and stroke. People with RA may not be able to exercise very easily, and some of the drugs used to treat RA may increase blood pressure.
  • Some of the drugs used to treat RA suppress the immune system. This may be a factor for the increased risk of developing infections and certain cancers.
  • Poor mobility and steroid drugs increase the risk of developing osteoporosis.
  • Some of the drugs that are used to treat RA can upset the lining of the gut. This sometimes causes gut and stomach problems.

Other complications

Other complications which may develop include:

  • Carpal tunnel syndrome. This is relatively common. It causes pressure on the main nerve going into the hand. This can cause pain, tingling and numbness in parts of the hand. (See separate leaflet called 'Carpal Tunnel Syndrome' for details.)
  • Tendon rupture sometimes occurs (particularly the tendons on the back of the fingers).
  • Cervical myelopathy. This is an uncommon but serious complication of severe, long-standing RA. It is caused by a 'dislocation' of joints at the top of the spine. This can cause pressure on the spinal cord.

What are the treatments for rheumatoid arthritis?

RA can be cured occasionally. It can be treated to reduce pain, stiffness, and damage to joints. The main aims of treatment are:

  1. To reduce pain and stiffness in affected joints as much as possible.
  2. To prevent joint damage as much as possible.
  3. To minimise any disability caused by pain, joint damage, or deformity.
  4. To reduce the risk of developing associated conditions such as heart disease.

Treatment aim 1 - to reduce pain and stiffness

During a flare-up of inflammation, if you rest the affected joint(s) it helps to ease pain. Special wrist splints, footwear, gentle massage, or applying heat may also help. Medication is also helpful. Drugs which may be advised by your doctor to ease pain and stiffness include the following:

Non-steroidal anti-inflammatories

These are sometimes just called 'anti-inflammatories' and are good at easing pain and stiffness and also help to reduce inflammation. There are many types and brands. Each is slightly different to the others, and side-effects may vary between brands. To decide on the right brand to use, a doctor has to balance how powerful the effect is against possible side-effects and other factors. Usually one can be found to suit. However, it is not unusual to try two or more brands before finding one that suits you best.

The leaflet which comes with the tablets gives a full list of possible side-effects. The most common side-effect is stomach pain (dyspepsia). An uncommon but serious side-effect is bleeding from the stomach. Your doctor may prescribe another drug to 'protect the stomach' from these possible problems. If you develop abdominal (stomach) pains, pass blood or black stools, or vomit blood whilst taking anti-inflammatory painkillers, stop taking the tablets and see a doctor urgently.

Painkillers

Paracetamol often helps. This does not have any anti-inflammatory action, but is useful for pain relief in addition to, or instead of, an anti-inflammatory. Codeine is another painkiller that is sometimes used.

Steroids

Steroids are good at reducing inflammation. However, because of the problem of possible side-effects, steroids are not recommended for routine use. This is not to say that they are never used. The main side-effects from steroids occur when they are used for more than a few weeks. Therefore, a short course of steroid tablets such as prednisolone is sometimes used. This may be prescribed to treat a flare-up which has not been helped much by a non-steroidal anti-inflammatory. A short course of steroids may also be used whilst waiting for a disease modifying drug (see below) to take effect.

An injection of steroid directly into a joint is sometimes used to treat a bad flare-up in one particular joint.

The serious side-effects that may occur if you take steroids for more than a few weeks, or if you have injections frequently, include: thinning of the bones (osteoporosis), thinning of the skin, weight gain, muscle wasting and an increased risk of serious infection.

Note: non-steroidal anti-inflammatories, ordinary painkillers, and steroids ease the symptoms of RA. However, they do not alter the progression of the disease or prevent joint damage. You do not need to take them if symptoms settle between flare-ups.

Treatment aim 2 - to prevent joint damage as much as possible

Disease-modifying drugs

There are a number of drugs called disease-modifying antirheumatic drugs (DMARDs). These are drugs that ease symptoms but also reduce the damaging effect of the disease on the joints. They work by blocking the way inflammation develops in the joints (by blocking certain chemicals involved in the inflammation process). DMARDs include: sulfasalazine, methotrexate, gold injections, gold tablets, penicillamine, leflunomide and hydroxychloroquine. It is these drugs that have improved the outlook (prognosis) in recent years for many people with RA.

It is usual to start a DMARD as soon as possible after RA has been diagnosed. This is to try and limit the disease process as much as possible. In general, the earlier you start one, the more effective it is likely to be.

DMARDs have no immediate effect on pains or inflammation. It can take several weeks, and sometimes several months, before you notice any effect. Therefore, it is important to keep taking a DMARD as prescribed, even if it does not seem to be working at first. After starting a DMARD, many people continue to take an anti-inflammatory tablet for several weeks until the DMARD starts to work. Once a DMARD is found to help, the dose of the anti-inflammatory tablet can be reduced or even stopped. It is then usual to take a DMARD indefinitely.

Other DMARDs include azathioprine, cyclosporin, and cyclophosphamide. These are usually reserved for people who do not respond well to the more commonly used DMARDs, due to the risk of serious side-effects.

Each DMARD has different possible side-effects. If one does not suit, a different one may be fine. Some people try two or three DMARDs before one is found to suit. (Some side-effects can be serious. These are rare and include damage to the liver and blood producing cells. Therefore, it is usual to have regular tests - usually blood tests - whilst you take a DMARD. The tests look for some possible side-effects before they become serious.)

Newer disease modifying drugs

A new class of drugs which have recently been developed are drugs that modify the effect of TNF-alpha. The chemical TNF-alpha plays an important role in causing inflammation in joints. Blocking the effect of TNF-alpha has been shown to reduce damage to joints, and reduce symptoms. Drugs which modify or block the effect of TNF-alpha include: etanercept, infliximab, adalimumab, and anakinra. They show promise but their long-term benefits are still being evaluated.

One problem with these drugs is that they need to be given by injection. They are also expensive. Recent guidelines state that one may be tried if there has been little success when using standard DMARDs.

Treatment aim 3 - to minimise disability as much as possible

  • As far as possible, try to keep active. The muscles around the joints will become weak if they are not used. Regular exercise may also help to reduce pain and improve joint function. Swimming is a good way to exercise many muscles without straining joints too much. A physiotherapist can advise on exercises to keep muscles around joints as mobile and strong as possible. They may also advise on splints to help rest a joint if needed.
  • If such things as your grip or mobility become poor, an occupational therapist may advise on adaptations to the home to make daily tasks easier.
  • If you develop a joint deformity then surgery to correct it may be an option. If severe damage occurs to a joint, operations such as knee or hip replacements are an option.

Treatment aim 4 - to reduce the risk of developing other diseases

General measures to help treat fibromyalgia/rheumatoid arthritis/osteoarthritis/spondylitis/spondylosis

Exercise

If possible, exercise regularly. This helps to strengthen the muscles around affected joints, to keep you fit, and to maintain a good range joint movement. Swimming is ideal for most joints, but any exercise is better than none. Many people can manage a regular walk.

Weight control

If you are overweight, try to lose some weight as the extra burden placed on back, hips, and knees can make symptoms worse. Even a modest weight loss can make quite a difference.

  • Wearing a Lubar belt or knee brace.

These measures slightly alter the distribution of weight and pressure on the knee joint, which is why they are thought to ease symptoms in some cases. A podiatrist or physiotherapist can advise exactly how to use them.

Braces or supports may also be helpful for other joints affected by OA. For example, a support around the thumb for painful thumb OA.

Daily walking for 30 to 45 minutes with or without Walking aids

If you have OA of your hip or knee, when walking try using a cane (walking stick). Hold it in the hand on the opposite side of the body to the affected joint. This takes some pressure off the affected joint and helps to ease symptoms in some cases.

Diet - Vitamins, minerals, calcium should be obtained from natural dietary resources and 

not by 'vitamin tablets/capsules' which can increase your risk of 'medicinal side-effects'. 

Fruits, Salads, green vegetables/leaves, Sprouts -250 grammes

Curd/Yoghurt -250 grammes, 

Lemon juice with little salt/sugar.

Water -5-6 lit per day or more, daily slow sustained yoga type physiotherapy exercises as given in website is essential for good health of bones and body.

Daily brisk/speed walking for 1 hour, getting enough vitamin D from your diet, sunlight will decrease your risk.

Cycling outdoors and non-gym outdoor exercises such as brisk walking, using stairs at home and office, walk at work bring overall improvement in health, well being besides controlling and curing many diseases such as Hypertension, diabetes, depression, cancer, osteoporosis, arthritis, muscular pains and joint pains. 

Physical activity. Not exercising and being inactive or staying in bed for long periods can increase your risk.

Smoking. Smokers harm their blood circulation, damage all tissues in body by free radicals of smoke and absorb less calcium from their diets.

Medications. Some commonly used medicines can cause loss of bone mass. These include steroids used to control arthritis and asthma; some drugs used to treat seizures; some cancer drugs; and, too much thyroid hormone.

Low body weight. Women who are very thin – and small-boned – are at greater risk for osteoporosis.


Physiotherapy help if unable to follow correct exercises

Sometimes advice or treatment from a physiotherapist is helpful. For example:

  • For advice on which exercises to do to strengthen the muscles above the knee (quadriceps) if you have arthritis of the knee. Strengthening the 'quads' has been shown to improve symptoms caused by arthritis of the knee.
  • For advice on how to keep active and fit.
  • For advice on shoes insoles, knee braces, taping to the knee, and how to use walking aids properly (to make sure you have one of the correct height).

Manipulation and stretching around affected joints may be helpful. This is something that physiotherapists may also be able to help with.

Occupational therapy

An occupational therapist may be able to help if you need aids or modifications to your home to cope with any disability caused by OA. Special devices, such as tap turners to help with turning on a tap, may mean that you can carry out tasks around the house more easily.

Other therapies

  • Some people have found that TENS (Transcutaneous Electrical Nerve Stimulator) machines help to ease pain from OA. A TENS machine delivers small electrical pulses to the body via electrodes placed on the skin.
  • Acupuncture may also help to ease symptoms in some cases.
  • Some people find that they can also get some pain relief from using hot or cold packs on the affected joint(s). This is also called thermotherapy. You can use a hot water bottle filled with either hot or cold water and apply it to the affected area. Or, special hot and cold packs that can either be cooled in the freezer, or heated in a microwave, are also available.

Medicines used to treat fibromyalgia/rheumatoid arthritis/osteoarthritis/spondylitis/spondylosis

Paracetamol

Paracetamol is the common medicine used to treat OA. It often works well to ease pain. It is best to take it regularly to keep pain away, rather than 'now and again' when pain flares up. A normal adult dose is two 500 mg tablets, four times a day. It usually has little in the way of side-effects, and you can take paracetamol long-term without it losing its effect.

Anti-inflammatory painkillers

You may find that a topical preparation of an anti-inflammatory painkiller that you rub onto the skin over affected joints is helpful instead of, or in addition to, paracetamol tablets. This may be particularly helpful if you have knee or hand OA. Compared to anti-inflammatory tablets, the amount of the drug that gets into the bloodstream is much less with topical preparations, and there is less risk of side-effects (see below).

Anti-inflammatory painkillers that are taken by mouth are not used as often as paracetamol. This is because there is a risk of serious side-effects, particularly in older people who take them regularly. However, one of these medicines is an option if paracetamol or topical anti-inflammatories do not help. Some people take an anti-inflammatory painkiller for short spells, perhaps for a week or two when symptoms flare up. They then return to paracetamol or topical anti-inflammatories when symptoms are not too bad. There are many different brands of anti-inflammatory painkillers. If one does not suit, another may be fine.

Side-effects may occur in some people who take anti-inflammatory painkillers:

  • Bleeding from the stomach is the most serious possible side-effect. This is more of a risk if you are over 65, or have had a duodenal or stomach ulcer, or if you are also taking low-dose aspirin. Stop the medicine and see a doctor urgently if you develop indigestion, upper abdominal pain, or if you vomit or pass blood. Read the leaflet that comes with the medicine for a list of other possible side-effects. You doctor can prescribe another medicine that can help to protect your stomach if you are taking anti-inflammatory painkillers in the long-term. You should discuss this with them.
  • Some people with asthma, high blood pressure, kidney failure, and heart failure may not be able to take anti-inflammatory painkillers.

Codeine

Codeine is sometimes combined with paracetamol for added pain relief. Constipation is a common side-effect from codeine. To help prevent constipation, have lots to drink and eat a high fibre diet.

Capsaicin cream

This cream is made from chilli peppers and it works by blocking the nerve signals that send pain messages to the brain. It may be helpful if you have knee or hand OA. It takes a while for the effects of this cream to build up and may take around one month to get the maximum benefit. You should rub in a pea-sized amount of cream around the affected joint four times a day, and not more often than every four hours.

Don't use this cream on broken or inflamed skin. You may notice some burning after you apply the cream but this tends to improve the longer you have used it. Avoid having a hot bath or shower, before, or after, applying the cream because it may make the burning sensation worse. Also, be careful to wash your hands after applying the cream. Because it is made from chilli peppers, it can cause burning if it gets into your eyes, mouth or around your genital area.

An injection of antiinflammatory medicine

An injection directly into a joint is useful if a joint becomes badly painful / inflamed.


Treatments that are not normally recommended

Glucosamine, cartilage regenerative drugs are Usually not helpful in long term as no reliable studies on them. besides they may affect liver function and kidneys.

Hyaluronic acid

The use of regular injections of hyaluronic acid directly into a joint is a relatively new treatment that has been tried for OA. The theory is that it may help with 'lubrication' and 'shock absorption' in a damaged joint. It may produce a small beneficial effect in some people. However, the National Institute for Health and Clinical Excellence (NICE) has looked at the use of hyaluronic acid as a possible treatment for OA and does not recommend its use. This is because there is little evidence that it is effective.

Chondroitin

This is another food supplement that has become popular as a potential treatment for OA. It is a chemical that is part of the make-up of normal cartilage. A recent big study showed that chondroitin has little, or minimal, effect on reducing symptoms in people with OA. Also, NICE does not recommend the use of chondroitin for the treatment of OA. This is because they could find no clear evidence from studies to show that it is an effective treatment.

Surgery for osteoarthritis/spondylitis/fibromyalgia/rheumatoid arthritis/osteoarthritis/spondylitis/spondylosis

Most people with OA/spondylitis do not have it badly enough to need surgery. However, OA of a joint may become severe in some cases. Some joints can be replaced with artificial joints. Hip and knee replacement surgery has become a standard treatment for severe OA of these joints. Some other joints can also be replaced.

Surgery

Seldom is surgery used to treat spondylosis. Most patients respond well to non-surgical treatment for spinal osteoarthritis.

As mentioned, if you have RA you have an increased risk of developing diseases such as heart disease, stroke, osteoporosis, and certain cancers. Therefore, you should consider doing what you can to reduce the risk of these conditions by other means.

For example, if possible:

  • Eat a good healthy diet and exercise regularly.
  • Lose weight if you are overweight.
  • Do not smoke. (In addition to increasing the risk of cancer, heart disease and stroke, smoking may also make symptoms of RA worse.)
  • If you have high blood pressure, diabetes, or a high cholesterol level, they should be well controlled on treatment.

See leaflets called 'Preventing Heart Disease and Stroke' and 'Osteoporosis' for more details.

Immunisations

To prevent certain infections, you should have:

  • An annual 'flu jab if you are over the age of 65 years, or are taking immunosuppressive drugs, or are taking steroids equivalent to 20 mg or more of prednisolone each day for more than a month.
  • A 'one-off' pneumococcal immunisation if you are over the age of 65 years, or are taking immunosuppressive drugs, or are taking steroids equivalent to 20 mg or more of prednisolone each day for more than a month.

Other treatments

Some people try complementary therapies such as special diets, bracelets, acupuncture, etc. There is little research evidence to say how effective such treatments are for RA. In particular, beware of paying a lot of money to people who make extravagant claims of success. For advice on the value of any treatment it is best to consult a doctor, or contact one of the groups below.

What is the outlook (prognosis)?

The outlook regarding joint damage is perhaps better than many people imagine.

  • About 2 in 10 people with RA have a relatively mild form of the disease, and can continue to do most normal activities for many years after the condition first starts.
  • About 1 in 10 people with RA become severely disabled.
  • About 7 in 10 fall somewhere in between with varying degrees of difficulties and disability. Most will have to modify their lifestyle to some extent, but can expect to lead a full life.

However, these figures are probably becoming out of date as treatment has improved in recent years. Symptoms can often be well controlled with medication. Because of the newer and better drugs, in particular the newer disease modifying drugs, the outlook for a person who is diagnosed with rheumatoid arthritis these days is likely to be much better than it was a few years ago. Follow up studies of people being treated with the newer drugs should give a clearer idea of prognosis over the next few years.

Another factor to bear in mind is that because of the increased risk of developing 'associated diseases' such as heart disease (see above), the average life expectancy of people with RA is a little reduced compared to the general population. This is why it is important to tackle any factors that you can modify such as smoking, diet, weight, etc.

In summary

  • Rheumatoid arthritis can range from relatively mild to severe.
  • The outlook cannot be predicted for an individual when the disease starts.
  • RA can be treated to reduce pain, stiffness, and damage to joints. Treatment usually includes:
    • A disease-modifying drug which reduces joint damage. The earlier one is started, the less damage is likely to occur in the joints. You should take this all the time. It may take several weeks to begin working.
    • An anti-inflammatory to ease pain and reduce inflammation. This helps to ease symptoms but does not affect the progress of the disease. You do not need to take this if symptoms settle.
  • A painkiller such as paracetamol or codeine may be added for extra pain relief.
  • Other treatments such as physiotherapy, occupational therapy, and surgery may also be advised, depending on the severity of the disease and other factors.
  • If possible, leading a healthy lifestyle such as not smoking, eating healthily, taking regular exercise, etc, can help to reduce the chance of developing associated diseases such as heart disease, stroke, osteoporosis, and certain cancers.

Further help and advice

Arthritis Research Campaign - ARC

Copeman House, St Marys Court, St Marys Gate, Chesterfield, Derbyshire, S41 7TD.
Tel: 0870 850 5000 Web: www.arc.org.uk

Arthritis Care

18 Stephenson Way, London, NW1 2HD
Helpline: 0808 800 4050 Web: www.arthritiscare.org.uk

National Rheumatoid Arthritis Society (NRAS)

Unit B4 Westacott Business Centre, Westacott Way, Littlewick Green, Maidenhead, Berks, SL6 3RT
Helpline: 0800 298 7650 Web: www.rheumatoid.org.uk

References

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