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BY 4.0 license Open Access Published by De Gruyter October 19, 2023

Association between steroid use and concussions among high school athletes: a cross-sectional analysis of the Youth Risk Behavior Surveillance System

  • Kennedy Sherman ORCID logo EMAIL logo , Phillip Tyree ORCID logo , Alicia Ito Ford , Anna Mazur , Douglas Nolan and Micah Hartwell ORCID logo

Abstract

Context

In 2017, there were almost 2.5 million high school students who experienced a concussion while playing a sport, raising concern for the neurologic problems that they could face. Some of these athletes may seek to gain a competitive advantage in their sport by utilizing substances like steroids. However, steroid use can cause increased aggression and body mass index (BMI), which might lead to heightened risk for concussions. Despite extensive research, we found no previous evidence linking these two factors.

Objectives

This analysis aims to investigate steroid use trends in high school athletes and to determine whether there is an association between steroid use and concussions in these athletes.

Methods

We conducted a cross-sectional analysis of the cumulative Youth Risk Behavior Surveillance System (YRBSS). Respondents were added if they participated in sports and answered the steroid and concussion prompts. Demographic variables were assessed including age, grade, BMI, gender, and race/ethnicity.

Results

We found that 3.7 % (n=2991) of high school athletes reported previous steroid use and that 20.7 % (n=2273) reported having sustained a concussion. There was a statistically significant difference in steroid use by race/ethnicity (p<0.001), with the highest rate of use (7.2 %) among American Indian/Alaska Natives (AI/AN). A significantly higher prevalence of steroid use occurred in athletes who were males (4.7 %) than females (2.5 %) and in athletes with a BMI>95 % (5.2 %) compared with those with a BMI between 85 and 95 % (3.9 %) and <85 % (3.5 %) (χ2=135.1, p<0.001 and χ2=16.3, p<0.001, respectively). Further, our results showed that the prevalence of steroid use among high school athletes decreased from 3.4 % in 1999 to 1.9 % in 2019, with the most drastic drop occurring between 2015 and 2019—declining 1.9 %. Whereas 19.6 % of athletes reported a concussion without steroid use, 54.6 % of steroid-utilizing athletes reported having experienced a concussion—a statistically significant finding (adjusted odds ratio [AOR]=4.3; 95 % CI: 3.2–5.9). Finally, compared with White athletes, we found that AI/AN athletes were significantly more likely to have sustained a concussion (AOR=2.3; 95 % CI=1.2–4.3).

Conclusions

Although our study found decreasing rates of steroid use among high school athletes from 1999 through 2019, our results also show that steroid use is significantly associated with sustaining a concussion. Additionally, the data from YRBSS also demonstrates that AI/AN high school athletes are more likely to utilize steroids and sustain a concussion. Given the long-term consequences of traumatic brain injuries, we recommend that coaches should be aware of potential steroid use among players, and that coaches, athletic trainers, and physicians should all be aware of concussion protocols and remove players from games for evaluation when a concussion is suspected.

Concussions continue to be a universal medical problem in people of all ages. Between 1997 and 2019, it was estimated that the United States had nearly 4.5 million people who presented to emergency departments with a concussion [1]. The prevalence of concussions was highest among children between the ages of 5 and 14, followed by adolescents and young adults—most commonly due to sports-related injuries [1]. DePadilla et al. [2] estimated that during 2017, nearly 2.5 million (15.1 %) US high school students incurred one or more concussions during participation in a sport or physical activity. However, the prevalence of concussions may be underestimated due to underreporting [2]. These high rates are of particular concern due to the potential long-term consequences that may occur including psycho-behavioral issues, cognitive deficits [3], and the possibility of chronic traumatic encephalopathy (CTE) [3]—because nearly 6.0 % of high school students had two or more concussions across one year [2]. Sports that have higher rates of concussions, such as football or soccer, also tend to be sports where a competitive edge is sought—sometimes through the misuse of substances such as steroids.

The use of steroids among adolescent athletes is a well-recognized issue among high school athletes. The National Federation of State High School Associations (NFHS) reports that 0.7 % of National Collegiate Athletic Association (NCAA) male athletes utilize steroids, with a lifetime prevalence of adolescent steroid use ranging from 1 % to 12 %, despite the organization banning these substances [4]. According to White and Noeun [5], the most recent comprehensive review concerning the prevalence of adolescent steroid use showed it to be between 5 % and 7 % in 2012 and 2013. Long-term use of steroids leads to several potential physiological side effects, including fertility issues and liver problems, in addition to an increase in high blood pressure and cardiac problems [6]. From a neurocognitive perspective, steroid use may increase aggression and anxiety while also lowering impulse control [6, 7]. These neurobehavioral shifts may lead to increased aggressive play and a subsequent heightened risk for concussions, with cardiac risks increasing the possibility of prolonged recovery from concussions. Further, with increased testosterone from steroids, athletes are also likely to increase fat-free body mass, have higher muscle volumes, and have increased muscle strength—amplifying the momentum and impact of head-on collisions during sports [8].

Because the literature on steroid use among high school athletes is sparse, and usage rates have not been assessed since 2013, it is important to understand and report trends in substance use among high school athletes. Further, we posit that steroid usage may be linked to concussions among this demographic; however, we found no previous evidence linking the two variables. Thus, given the potential of steroids to be an underlying or mediating cause of concussions among US high school athletes, our primary objectives were: 1) to assess rates of steroid use among US high school athletes; and 2) to determine the association between concussions and the use of steroids. Our secondary objective was to determine whether race/ethnicity, gender, body mass index (BMI), or education grade level were related to increased concussions. As a result of previous studies, we hypothesize that trends in steroid use among high school athletes may have decreased in recent years due to new drug testing guidelines; however, given that steroid use is in line with risk-taking behaviors, we hypothesize that concussions will be more prevalent within this group of athletes.

Methods

Data sources

To evaluate the relationship between steroid use and concussions, we performed a cross-sectional analysis of the Youth Risk Behavior Surveillance System (YRBSS). We analyzed the YRBSS to identify the prevalence of risky health behaviors and to analyze their trends in US high school students through self-administered surveys. This system has biannually collected data since 1999 to create a longitudinal sample that is nationally representative. Our study utilized cumulative YRBSS data from 136 schools that resulted in 217,340 respondents [9].

Eligibility criteria

Respondents were included if they answered that they participated in at least one team sport from the YRBSS prompt: “During the past 12 months, on how many sports teams did you play? (Count any teams run by your school or community groups).” We excluded respondents who did not participate in any sports.

Concussions and steroid use

Concussion prevalence was determined utilizing the YRBSS prompt: “During the past 12 months, how many times did you have a concussion from playing a sport or being physically active?” We included all respondents who answered this question and split them into two groups. Respondents who answered, “0 times” had not been concussed in the past year, whereas respondents who answered, “1 time,” “2 times,” “3 times,” or “4 or more times” were classified as previously concussed.

To discover the prevalence of steroid use, respondents were included if they answered the YRBSS prompt, “During your life, how many times have you taken steroid pills or shots without a doctor’s prescription?” Two groups were established: group 1 consisted of those who answered, “0 times” and group 2 consisted of steroid users who answered, “1 to 2 times,” “3 to 9 times,” “10 to 19 times,” “20 to 39 times,” and “40 or more times.”

Demographic variables

Our data consisted of various demographic variables including gender, race/ethnicity, BMI, and education grade level. High school grade levels (9th through 12th) were included in our data, whereas “ungraded or other grade” was excluded. Race/ethnicity was evaluated with the prompts: “What is your race?” and “Are you Hispanic or Latino?” which resulted in the categories: White, Black or African American, American Indian/Alaska Native (AI/AN), Hispanic or Latino, Asian, Native Hawaiian/Other PI, and Multi-racial. Age and sex reference data from the 2000 Centers for Disease Control and Prevention (CDC) growth charts were utilized to create the BMI categories <85 %, 85–95 %, and >95 %.

Statistical analysis

Utilizing the cumulative YRBSS data, the sample size (n) of high school athletes was reported and the weighted prevalence was calculated by grade, sex, race/ethnicity, and BMI category. We then utilized the same statistics to estimate whether the athletes had ever utilized steroids illegally and analyzed the associations utilizing design-based chi-square (X 2) tests. We also estimated the weighted prevalence of steroid use by YRBSS cycles, which occur biannually (from 1999 through 2019). Next, we created binary and multivariable logistic regression models to assess the associations between experiencing a concussion and utilizing steroids. This was calculated utilizing odds ratios (ORs) and adjusted odds ratios (AORs).

Results

Demographics of high school athletes

Within the YRBSS data, 80,561 (N=85,610) respondents reported playing on a sports team in the past year. The respondents were equally distributed between 17,552 and 21,161 (16,986 and 25,326 weighted estimate) among 9th to 12th graders (Table 1). The majority were White (61.8 %), followed by Hispanic/Latino (16.5 %) and Black or African American (12.9 %), with AI/AN athletes being least represented (0.7 %). Male athletes were among the majority of respondents with 55.3 %, in comparison with female athletes (44.7 %). The majority of the high school athletes were in the <85 % BMI percentile (75.8 %), with the fewest being in the >95 % BMI percentile (10.3 %).

Table 1:

Demographics of high school athletes by steroid use history.

No steroid use Steroid use Total Design-based chi-square, p-Value
n, N (%) n, N (%) n, N (%)
Grade
 9th 20,311, 24,350 (96.2) 850, 976 (3.9) 21,161, 25,326 (30.0) 1.0, 0.4
 10th 19,598, 21,799 (96.3) 776, 850 (3.8) 20,374, 22,649 (26.7)
 11th 19,042, 19,069 (96.6) 693, 677 (3.4) 19,735, 19,746 (23.3)
 12th 16,880, 16,359 (96.3) 672, 627 (3.7) 17,552, 16,986 (20.1)
Race/ethnicity
 White 34,759, 50,048 (96.4) 1,284, 1,845 (3.6) 36,043, 51,893 (61.8)
 American Indian/Alaska Native 838, 555 (92.8) 62, 43 (7.2) 900, 598 (0.7) 5.8, <0.001
 Asian 2,356, 2,282 (97) 70, 70 (3.0) 2,426, 2,353 (2.8)
 Black or African American 14,404, 10,448 (96.7) 473, 362 (3.4) 14,877, 10,810 (12.9)
 Hispanic/Latino 19,230, 13,254 (95.7) 902, 596 (4.3) 20,132, 13,850 (16.5)
 Native Hawaiian/Other PI 596, 584 (92.9) 46, 45 (7.1) 642, 629 (0.8)
 Multi-racial 2,945, 3,701 (96.3) 136, 142 (3.7) 3,081, 3,843 (4.6)
Sex
 Female 34,808, 36,995 (97.5) 915, 953 (2.5) 35,723, 37,948 (44.7) 135.1, <0.001
 Male 41,159, 44,736 (95.3) 2,112, 2,205 (4.7) 43,271, 46,941 (55.3)
BMI categorya
 <85 % 56,984, 62,265 (96.5) 2,167, 2,269 (3.5) 59,151, 64,534 (75.8) 16.3, <0.001
 85–95 % 10,977, 11,441 (96.1) 457, 463 (3.9) 11,434, 11,903 (14.0)
 >95 % 8,291, 8,293 (94.8) 441, 459 (5.2) 8,732, 8,752 (10.3)
  1. BMI, body mass index; CDC, Centers for Disease Control and Prevention; PI, Pacific Islander. aBased percentile for BMI, based on sex- and age-specific reference data from the 2000 CDC growth charts. Bold values indicate statistically significant findings.

Steroid use

Our results showed that 3.7 % (n=2,991, N=3,130) of high school athletes reported that they had taken steroids. The highest rates of steroid use occurred among AI/AN (7.2 %) and Native Hawaiian/Other PI (7.1 %), followed by Hispanic/Latino (4.3 %), with the lowest rate reported in Asian (3 %), and all other groups were between 3 and 4.3 %—a statistically significant difference between all groups (X 2=5.8, p<0.001). There was also a significant difference between steroid use and both sex (X 2=135.1, p<0.001) and BMI category (X 2=16.3, p<0.001). Male athletes had a higher prevalence of steroid use (4.7 %) compared with female athletes (2.5 %). While athletes with a BMI>95 % had the highest rate of steroid use (5.2 %), the lowest rate occurred in athletes with a BMI<85 % (3.5 %). The relationship between grade level and steroid use was not found to be statistically significant.

Steroid use trends

As shown in Figure 1, we found that the weighted prevalence of steroid use decreased from 3.4 % in 1999 to 1.9 % in 2019. Within this period, we also discovered a spike in steroid use in 2001 and 2003 (5.3 and 4.4 %, respectively). In contrast, there was an apparent decrease in steroid use among athletes from 2015 through 2019, dropping from 3.8 to 1.9 % (Figure 1).

Figure 1: 
Trends in steroid use (weighted %) among high school athletes from 1999 through 2019.
Figure 1:

Trends in steroid use (weighted %) among high school athletes from 1999 through 2019.

Concussions and the association with steroid use

Among high school athletes who responded to the question regarding concussions (n=11,425, N=13,633), 20.7 % (n=2,273, N=2,815) reported having a concussion. While 19.6 % of athletes who never utilized steroids sustained a concussion, concussion was reported in 54.6 % of athletes who were steroid users. Based on these findings, athletes reporting steroid use were significantly more likely to have a concussion (AOR=4.3; 95 % CI: 3.2–5.9) compared with those who reported no steroid use, while controlling for grade, race/ethnicity, sex, and BMI category. Within our adjusted models, we also found that compared with White athletes, AI/AN athletes were significantly more likely to have sustained a concussion (AOR=2.3; 95 % CI=1.2–4.3). Further, it was more likely for a concussion to be reported by males compared with females and from athletes with a BMI>95 % compared with those with a BMI<85 % (Table 2).

Table 2:

Association of demographics, steroid use, and concussions.

(%) With concussion OR (95 % CI) t, p-Value AOR (95 %CI) t, p-Value
Steroid use
 No 19.6 1.0 [reference] 1.0 [reference]
 Yes 54.6 4.9 (3.7–6.6) 10.8, <0.001 4.3 (3.2–5.9) 9.5, <0.001
Grade
 9th 20.8 1.0 [reference] 1.0 [reference]
 10th 19.8 0.9 (0.8–1.1) −0.8, 0.5 1.0 (0.8–1.1) −0.6, 0.5
 11th 22.4 1.1 (0.9–1.3) 1.0, 0.3 1.1 (0.9–1.3) 1.0, 0.3
 12th 19.1 0.9 (0.7–1.1) −1.1, 0.3 0.9 (0.7–1.1) −1.3, 0.2
Race
 White 20.5 1.0 [reference] 1.0 [reference]
 American Indian/Alaska Native 40.6 2.7 (1.4–5.0) 3.1, 0.0 2.3 (1.2–4.3) 2.5, 0.0
 Asian 15.0 0.7 (0.5–1.0) −2.0, 0.1 0.7 (0.5–1.0) −1.9, 0.1
 Black or African America 22.1 1.1 (0.9–1.3) 1.0, 0.3 1.0 (0.9–1.3) 0.4, 0.7
 Hispanic/Latino 19.9 1.0 (0.8–1.1) −0.5, 0.6 0.9 (0.8–1.1) −1.3, 0.2
 Native Hawaiian/Other PI 22.5 1.1 (0.6–2.0) 0.4, 0.7 1.0 (0.6–1.8) 0.0, 1.0
 Multi-racial 20.8 1.0 (0.8–1.3) 0.2, 0.9 1.0 (0.8–1.3) 0.1, 0.9
Sex
 Female 18.4 1.0 [reference] 1.0 [reference]
 Male 22.6 1.3 (1.2–1.5) 4.4, <0.001 1.3 (1.1–1.4) 3.8, <0.001
BMI categorya
 <85 % 19.9 1.0 [reference] 1.0 [reference]
 85–95 % 22.1 1.0 (0.1–1.0) 0.1, 1.5 1.1 (0.9–1.3) 1.3, 0.2
 >95 % 23.8 2.0 (0.0–1.1) 0.1, 2.9 1.2 (1.0–1.4) 2.2, 0.0
  1. BMI, body mass index; CDC, Centers for Disease Control and Prevention; PI, Pacific Islander. aBased percentile for body mass index, based on sex- and age-specific reference data from the 2000 CDC growth charts. Bold values indicate statistically significant findings.

Discussion

Across the time span of the YRBSS data (1999–2019), we found that nearly 4.0 % of high school athletes reported utilizing steroids. Although this trend peaked in 2001 at 5.3 %, it stayed relatively consistent through 2015, before dropping to its lowest rate of 1.9 % in 2019. Although this drop in steroid use is an encouraging finding, we still found a significant relationship between steroid use and high school athletes experiencing a concussion. Increased concussions among high school athletes with a history of steroid use may be linked to the psychological effects of anabolic steroids.

Whereas some athletes may start utilizing substances to deal with stress or pressure, most turn to steroids in order to increase muscle strength and lean muscle mass, which can increase their BMI [10]. In a systematic review conducted by Piacentino et al. [7], weightlifters/bodybuilders who utilized anabolic androgenic steroids exhibited increased aggression in multiple studies, in comparison with those not utilizing steroids. This link may also help explain the increased likelihood of athletes with a higher BMI sustaining a concussion. Schmidt et al. [11] discovered that adolescent ice hockey players who were less aggressive experienced “head impact with less rotational acceleration” compared with their more aggressive teammates during practice. However, the aggression level did not affect the severity of head impact during games [11]. Although there is no evidence available on the direct association between steroid use and concussion prevalence, the combination of increased BMI and aggression due to steroid use may increase the potential for sustaining a concussion. Additionally, the athlete’s personality may also play a role, and athletes more prone to risk-taking behaviors are more likely to not only utilize steroids but also engage in risky play. However, this consideration may be more applicable to athletes with a history of impulsivity and impulsive decision-making, such as athletes with a history of attention deficit disorders, because previous research has shown links between attention deficit disorders and substance use, including steroid use [12].

Our results also showed that AI/AN athletes reported the highest rates of steroid use and were more likely to sustain a concussion than White athletes. Eagle et al. [13] found that AI/AN male adolescents had the highest concussion prevalence compared with male adolescents of other races/ethnicities. However, this study also found that among female adolescents, Native Hawaiian/Pacific Islander adolescents were more likely to sustain a concussion [13]. Kiedrowski and Selya [14] found that lifetime steroid use in adolescent AI/ANs was 29.5 % compared with Non-Hispanic Whites at 6.0 %. These studies suggest that AI/AN adolescents are at an increased risk of steroid use and concussion prevalence, which may warrant further investigation.

Our study presents novel findings that identify steroid use as a specific factor that may increase concussion risk. Although the prevalence rate of steroid use is decreasing among high school athletes, it is important to continue efforts to eliminate illicit steroid use due to its significant negative short-term side effects, including liver dysfunction, lipid panel changes, and stunted growth [5], as well as more severe long-term adverse effects, including male infertility, cardiovascular injury, brain damage, and kidney damage [6]. Alone, concussions may result in: cognitive impairment; mental health issues such as depression, anxiety, and substance use; or more severe long-term effects such as Alzheimer’s disease or CTE [3]. Separately, steroid use and concussions have numerous health consequences, and when combined, these effects may be amplified.

Recommendations

Our first recommendation for decreasing concussion prevalence in high school athletes is to preserve the Lystedt Law—a law stating that players must be removed from play after sustaining a suspected or actual concussion, athletes with a concussion must be cleared by a licensed health professional, and annual concussion education is required for players, parents, and coaches [15]. Within 3 years after passing the Lystedt Law, new and recurrent concussion rates started decreasing [15]. In order to improve concussion reporting, we suggest that states strengthen and revise their concussion laws. Yang et al. [16] found that new and recurrent concussions were reported more often in states with stricter laws and that states with more law revisions had lower recurrent concussion reporting rates.

Further, some sport-specific rule changes may be made based on previous research. Kriz and Roberts [17] found decreased concussion risks after: 1) removal of body checking in adolescent ice hockey, 2) changes to football kickoffs, and 3) regulation of home plate collisions in baseball, while Pfaller et al. [18] found that limiting full-contact football practices also reduced concussion risk. Although the long-term effects are unclear, we recommend providing concussion education to coaches, parents, and players due to short-term improvements, as suggested by Kriz and Roberts [17]. Although there are mixed results on how effective helmets, mouthguards, and headgear are in concussion prevention, rules regarding equipment should be updated to the most protective equipment available [19].

Although steroid use has been trending downward, we recommend the continuation of random drug testing in schools with the addition of notifying their parents of a positive result and requiring drug counseling. In a two-year study by Goldberg et al. [20], two different groups of high schools were compared with each other, one with random drug and alcohol testing and the other who deferred testing. If an athlete had a positive drug test, their parents were notified, and the athlete was required to undergo counseling [20]. Although there was no difference between athlete drug use in the first month of the study, there was less drug use in drug-tested athletes by the end of the first year, compared with the athletes at schools who deferred their testing [20]. Another evidence-based method to reduce steroid use among high school athletes is through implementing programs such as Adolescent Training and Learning to Avoid Steroids (ATLAS). ATLAS utilizes the team environment to educate players on steroid use and other drug use while also suggesting that healthy nutrition and exercise can be effective, healthy alternatives [21]. This program showed that athletes gained a better understanding of the effects of steroid use and improved their methods of drug refusal [21].

In addition to educating players, we recommend that the CDC update its Heads Up program “Brain Injury and Safety Tips” section to include steroid use as a possible risk factor for concussions in adolescents [22]. These guideline changes would allow physicians to provide parents and coaches with the most up-to-date information on concussion risks. Moreover, it is important to recognize the risks posed by steroid use in formal guidelines concerning the assessment of adolescent sports concussions. Guidelines regarding current adolescent concussions and return to play do not address previous anabolic steroid use in the evaluation or acknowledgment that the substance is a risk for future concussions [23], [24], [25]. We suggest that future revisions to these guidelines acknowledge steroids as a possible factor in re-injury among high school athletes.

Limitations

There are some limitations to our study. One limitation is that YRBSS data are self-reported by high school students who may have limited knowledge of what a concussion is, and the various symptoms observed. These concussion reports were not confirmed by medical records, so there could be some variation in concussion prevalence. Underreporting of concussions is also possible due to the concussion prompt asking for concussion history within a year; this is a long timeframe that could have led to inaccurate concussion reporting. Another limitation of our study included steroid use being assessed based on whether the athletes “ever” utilized steroids in their life. However, steroids might not have been utilized within the year period when their concussion was reported. Our final limitation was the use of YRBSS data that spanned 20 years, during which time there have been numerous rule and equipment changes to decrease the chances of sustaining a concussion while playing a sport. Given that AI/AN athletes have higher rates of steroid use and concussions, we recommend that researchers further investigate this phenomenon and potentially create culturally informed public health messaging to educate children and parents of these risks [26].

Conclusions

Our study determined that high school athletes who reported steroid use were significantly more likely to report having a concussion than those without a history of steroid use. We also found that compared with other groups, AI/AN high school athletes are more likely to both sustain a concussion and utilize steroids. For this reason, we recommend strengthening policies/laws for concussion reporting and recovery, considering more sport-specific rules to prevent concussions, and continuing random drug testing in high school athletes. Thus, research needs to continue to assess the role that both steroids and race/ethnicity play in concussion prevalence to improve the safety of these athletes.


Corresponding author: Kennedy Sherman, MHA, Office of Medical Student Research, Oklahoma State University College of Osteopathic Medicine at Cherokee Nation, 19500 E Ross Street, Tahlequah, OK 74464, USA, E-mail:

  1. Research ethics: Not applicable.

  2. Informed consent: Not applicable.

  3. Author contributions: K.S., P.T., and M.H. provided substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; all authors drafted the article or revised it critically for important intellectual content; all authors gave final approval of the version of the article to be published; and all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  4. Competing interests: Dr. Hartwell receives research support through the National Institutes for Justice unrelated to the current work and the Health Resources Services Administration. Dr. Ford reports receipt of funding from the Center for Integrative Research on Childhood Adversity and internal grants from Oklahoma State University Center for Health Sciences — all outside of the present work. All other authors state no conflict of interest.

  5. Research funding: None declared.

  6. Data availability: The raw data can be obtained on request from the corresponding author.

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Received: 2023-06-15
Accepted: 2023-09-18
Published Online: 2023-10-19

© 2023 the author(s), published by De Gruyter, Berlin/Boston

This work is licensed under the Creative Commons Attribution 4.0 International License.

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