Recreational handball-based training for people with type 2 diabetes: a feasibility trial

Martin Færch Andersen; Allan Riis; Henrik Foged Borup; Astrid Dall; Mie Torp; Rikke Hareskov Elversøe; Janus Laust Thomsen; Peter Vestergaard; Anne-Mette Lücke Dissing

doi:10.12688/f1000research.138689.1

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Research Article

Clinical trial

Recreational handball-based training for people with type 2 diabetes: a feasibility trial

[version 1; peer review: 1 approved with reservations]

Martin Færch Andersen ^1,2, Allan Riis^1,3, Henrik Foged Borup¹, [...] Astrid Dall¹, Mie Torp¹, Rikke Hareskov Elversøe¹, Janus Laust Thomsen^3,4, Peter Vestergaard⁴, Anne-Mette Lücke Dissing¹

Martin Færch Andersen ^1,2, Allan Riis^1,3, [...] Henrik Foged Borup¹, Astrid Dall¹, Mie Torp¹, Rikke Hareskov Elversøe¹, Janus Laust Thomsen^3,4, Peter Vestergaard⁴, Anne-Mette Lücke Dissing¹

PUBLISHED 07 Nov 2023

Author details Author details

¹ Department of Physiotherapy, University College of Northern Denmark, Aalborg, Denmark
² Centre for Applied Research in Mental Health Care (CARMEN), Mental Health Centre Glostrup, Copenhagen, Denmark
³ Research Unit for General Practice in Aalborg, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
⁴ Department of Clinical Medicine, Aalborg University, Aalborg, Denmark

Martin Færch Andersen
Roles: Conceptualization, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing

Allan Riis
Roles: Conceptualization, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing

Henrik Foged Borup
Roles: Investigation, Methodology, Writing – Review & Editing

Astrid Dall
Roles: Investigation, Methodology, Writing – Review & Editing

Mie Torp
Roles: Investigation, Methodology, Writing – Review & Editing

Rikke Hareskov Elversøe
Roles: Investigation, Methodology, Writing – Review & Editing

Janus Laust Thomsen
Roles: Methodology, Supervision, Writing – Review & Editing

Peter Vestergaard
Roles: Methodology, Writing – Review & Editing

Anne-Mette Lücke Dissing
Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Introduction

Type 2 diabetes mellitus (T2DM) is recognized as a serious public health concern with a considerable impact on people suffering from the disease and the society. The benefit of physical activity in the prevention and treatment of T2DM are well documented, however, a considerable proportion of individuals with T2DM have an inactive and sedentary lifestyle. Although most people with T2DM are aware of the importance of exercise, many are not interested in joining traditional exercise options, and long-term adherence is poor for those who do. Thus, we aim to investigate the feasibility of recreational handball-based training (HBT) for people diagnosed with T2DM.

Methods

This single-arm feasibility trial included adults (over 30 years) with a clinical diagnosis of T2DM. They were invited to participate in a 12-week HBT consisting of two weekly 60-minute exercise sessions. The outcome was feasibility, determined by adherence, exercise intensity, adverse events, dropout rate, and metabolic parameters.

Results

From September to December 2021, 10 people were included in the study. One participant dropped out because of illness and one participant dropped out due to suspected atrial fibrillation. Eight participants concluded the intervention and participated on average 86% (range 14–23) of the HBT sessions exercising with a mean heart rate of 73.4% (standard deviation (SD) 10.2) of individual maximum heart rate.

Conclusions

HBT for people diagnosed with T2DM was found feasible with a high attendance rate and clinically relevant exercise intensities. However, future randomized controlled trials about the effects of the handball intervention are needed.

Trial registration

This trial was registered in ClinicalTrials.gov (NCT05015946) on 23/08/2021.

Keywords

Exercise Therapy, Diabetes Mellitus, Type 2, Sports for Persons with Disabilities, Treatment Adherence and Compliance, Metabolism, Quality of Life, team handball training, team sports

Corresponding author: Martin Færch Andersen

Competing interests: No competing interests were disclosed.

Grant information: Martin Færch Andersen and Anne-Mette Lücke Dissing were internally funded by the University College of Northern Denmark.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Copyright: © 2023 Andersen MF et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Andersen MF, Riis A, Borup HF et al. Recreational handball-based training for people with type 2 diabetes: a feasibility trial [version 1; peer review: 1 approved with reservations]. F1000Research 2023, 12:1440 (https://doi.org/10.12688/f1000research.138689.1) First published: 07 Nov 2023, 12:1440 (https://doi.org/10.12688/f1000research.138689.1) Latest published: 07 Nov 2023, 12:1440 (https://doi.org/10.12688/f1000research.138689.1)

Introduction

Type 2 diabetes mellitus (T2DM) is recognized as a public health concern, in 2021 it was estimated that 537 million adults are living with diabetes.¹ T2DM is associated with severe complications such as retinopathy, nephropathy, neuropathy, and ultimately premature mortality primarily due to cardiovascular events,² and 35% of people with T2DM experience complications even before the time of diagnosis.³ As a consequence, T2DM influence individuals’ functional capacity and quality of life.⁴

The benefit of physical activity and exercise in the prevention and control of T2DM and its complications are well documented,⁵^,⁶ and is a cornerstone in the first-line treatment. However, a considerable proportion of people with T2DM are inactive and have a sedentary lifestyle and do not adhere to clinical recommendations.⁷^,⁸ Although most people with T2DM recognize the importance of exercise, many are not interested in joining formal, structured exercise programs and long-term adherence is poor for those who do.⁹ Thus, a need for new exercise opportunities that can effectively improve diabetes health, while endorsing high levels of motivation to ensure long-term adherence is needed.

During the recent decades, there has been an increased interest in practicing adapted recreational team sports in the treatment and control of noncommunicable diseases.¹⁰ There are indications, that team sport is motivating for a sedentary population,¹¹^–¹³ and may promote internal motivation which is a strong predictor of fidelity and adherence.¹¹ Most research in the field of recreational team sport has been conducted with a soccer-based intervention, however, recreational handball show similar demands to those described for recreational soccer.¹⁴^,¹⁵ Former trials show¹⁵^–²⁰ that recreational team handball for untrained adult men and women is an intermittent high-intensity exercise mode in the range of those found to have a positive effect on aerobic, anaerobic and musculoskeletal fitness in adult individuals. Furthermore, the exercise intensity was unaffected by past experience with handball or other sports.¹⁹ A 16-week recreational team handball intervention for 67 postmenopausal women with no experience with the sport, found that handball produced moderate-to-vigorous aerobic intensities and two weekly 60 minutes handball sessions resulted in 10% improvements in cardiorespiratory performance.²¹ However, the feasibility of handball in a clinical population has yet to be investigated.

Objective

We aimed to study the feasibility of recreational handball-based training (HBT) for people diagnosed with T2DM.

Methods

Ethical considerations

This trial was conducted according to the declaration of Helsinki and approved by the North Denmark Region Committee on Health Research Ethics (registration number N-20200006) on 17/06/2020. Participants provided written informed consent prior to baseline assessment.

This trial was registered in ClinicalTrials.gov identifier: NCT05015946. Registration date: 23/08/2021.

Trial design

Single-arm feasibility trial.

Participants

People older than 30 years with a clinical diagnosis of T2DM were eligible for inclusion. Potential participants who were prohibited by their general practitioner from participation in HBT were excluded. The local Diabetes Association in the municipality of Aalborg recruited study participants by advertising in their membership magazines.

Intervention

The intervention was delivered in an indoor municipal sports arena and consisted of 12 weeks of recreational HBT with two 60 minutes sessions per week. Each session included 1) 20 minutes of standardized warm-up, 2) 20 minutes of handball specific exercises and 3) 20 minutes of small-sided matches. To avoid injuries, no hard tackles were allowed, and the handballs used were light and made of soft material. The intervention was facilitated by BHF, DA, TM and ERH as part of their physiotherapy bachelor project. The intervention is illustrated in Table 1.

Table 1. Intervention description.

Standard handball-based training session
0–20 min	Standardized warm-up (comprising of running, strength training, coordination exercises, balance training, and flexibility exercises) based on the FIFA11+ concept,³³ modified to handball and untrained individuals.
21–40 min	Handball specific exercises (comprising running, jumping, throwing, and shooting on goals)
41–60 min	Small-sided matches (mainly 4v4 or 5v5) with no permanent goalkeeper on a 20×13 meters court.

Outcomes

Primary outcomes

The primary outcomes were feasibility of HBT, determined by adherence, adverse events, dropout rate, and the exercise intensity. Dropout was defined as individuals completing baseline tests but not the follow-up test. The exercise intensity was measured using heart rate (HR) monitors (Polar h10) at both sessions in week 2,7 and 12. Adverse events were recorded during the entire intervention period.

Further outcomes were change from baseline to 12 week on hemoglobin A1c (HbA1c) (HemoCue HbA1c 501), physical (PCSc) and mental health component (MCSc) measured with the Short Form 36 (SF36)²² and cardiovascular fitness measured with peak oxygen uptake (VO₂peak) during an incremental cycling test following a standard protocol. A bike ergometer (Corival Lode, Groningen, The Netherlands) was used with a direct measurement of oxygen consumption by breath-by-breath on Jaeger Masterscreen CPX (Intramedic A/S, Lyngby, Denmark).

Secondary outcomes

Secondary outcome measures were change from baseline to 12 week on self-care behavior measured with Diabetes Intention, Attitude and Behavior Questionnaire (DIAB-Q)²³ and physical activity levels measured with Physical Activity Scale 2 (PAS2),²⁴ cholesterol (total, low-density lipoprotein (LDL), high-density lipoprotein (HDL), and triglyceride (TG) (Accutrend Plus Cholesterol Meter), body composition (body mass index (BMI), body fat, lean body mass) (Tanita MC-180MA, Tokyo, Japan), visceral adipose tissue (hip/waist ratio) and resting blood pressure (Omron, M4-I).

Test procedure

After arriving at the test facility, the participants were informed about the procedure of the tests performed. Afterward, they were asked to rest for 10 min in a sitting position before applying the cuff on the left arm. Three measures were taken using an automatic blood pressure monitor and the lowest value of both diastolic and systolic blood pressure was used for calculations. HbA1c and cholesterol (total, LDL, TG, and HDL) were measured using a capillary blood sample. The fingertip was first disinfected. Then, blood was collected for both HbA1c and cholesterol. To measure waist circumference a standard measuring tape was placed between the lowest rib and the upper iliac crest after a normal exhalation. To find the hip circumference the measuring tape was placed at the widest part of the hip. A Tanita® digital scale with bioelectrical impedance was used to measure weight and body fat. The participants stepped barefooted onto the scale and were instructed to keep the handgrips slightly elevated from the torso. The VO₂peak test was initiated with a 5-min warm-up period on 50 watts, followed by a 25-watt increase per minute until exhaustion. The test was considered a VO₂max test if the respiratory exchange ratio (RER) value exceeded 1.10 and the O₂-consumption reached a plateau. Otherwise, it was categorized as a VO₂peak test.

Statistical analysis

Adherence was defined as the percentage of training sessions attended of the scheduled 24 sessions. Exercise intensities were merged into three timepoints by calculating the mean of the two weekly sessions in week 2, 7 and 12. Percent of heartrate maximum (HRmax) was calculated using an estimated maximum heart rate $(208 - (0.7 \times age)) .$ ²⁵ Statistics on adherence and intensities were conducted in Microsoft Excel (version 2302, Office 365). Results in within-group changes from baseline to 12 weeks are presented as median with minimum/maximum and analyzed using the Wilcoxon-rank test in SPSS (IBM SPSS Statistics 27) (RRID:SCR_002865). Statistical significance was set at p<0.05.

Sample size

From a convenience approach, a group of 10–15 participants was recruited in respect to the feasibility of small-sided matches on a single court.

Results

In September 2021, 15 interested people with T2DM were recruited and screened for eligibility. Two were diagnosed with Type 1 diabetes, and one was under 30 years old and thereby not eligible for inclusion. Two decided not to participate due to time and transportation. In total, 10 participants were included. During the intervention, one participant dropped out due to illness not related to the intervention, and one participant stopped due to suspected atrial fibrillation detected in the baseline assessment. Eight participants contributed with follow-up data. A study flowchart is presented in Figure 1 and participants’ characteristics at baseline in Table 2.

Figure 1. Flow diagram of study participants from eligibility screening to inclusion.

Table 2. Baseline characteristics.

Variables	Median (min-max)/n (%)
Age (years)	67 (44–77)
Sex (male)	4 (40%)
Completed university or college	5 (50%)
Employment full time	3 (30)
Married or cohabitant	6 (60%)
Medical profile
Diabetes age (years)	11 (4–20)
Receiving medicine for T2DM _{(Metformin, Ozempic)}	9 (90%)
Receiving medicine for hypertension _{(Cozaar, Ramipril, Candemox)}	8 (80%)
Receiving medicine for hypercholesterolemia _{(Atorvastatin)}	8 (80%)
HbA1c (mmol/mol)	49.5 (40–79)
Height (cm)	171 (162–186)
Weight (kg)	78.3 (68.1–105.0)
BMI (kg/m²)	29.15 (23.5–33.9)
Percentage fat (%)	37.5 (20.5–43.7)
Self-reported leisure-time physical activity
Sedentary (h/day)	4.1 (3–6)
Light activity such as walking and cleaning (h/week)	7.2 (3–14)
Moderate activity such as gardening and climbing stairs (h/week)	5.6 (2–12)
Vigorous activity such as running or competitive sports (h/week)	1.1 (0–10)

The eight participants attended a mean of 20 (range 14–23) of 24 training sessions, corresponding to an attendance rate of 83%. Mean HR during HBT, based on six training sessions in weeks 2, 7 and 12, was 121.3 beats per minute (standard deviation (SD) 17) corresponding to 73.4% (SD 10.2) of individual maximal HR. Time spent with a HR over 70% was 61.1% (SD 30.1), and time spent in the intensity zones 70–80%, 80–90% and 90–100% was 31.9% (SD 18.5), 21.6% (SD16.1) and 7.6% (SD 10.6) of total training time, respectively. The mean % of maximal HR in the first 20 minutes (warm-up) was 65.5% (SD 6.5), the middle 20 minutes (handball specific) was 74.8% (SD 8.4) and the last 20 minutes (matches) was 79.4% (SD 10.2). Individual peak HR was 130 bpm (SD 4.7) corresponding to 89.6% of HRmax (SD 2.9) measured in week 12. Mean exercise intensities are displayed in Table 3 and individual exercise intensities with one-minute frequency for all participants is illustrated in Figure 2a–f.

Table 3. Exercise intensities during Handball-based training.

Percent of individual maximal heart rate during training sessions
	0–20 minute	21–40 minute	41–60 minutes	0–60 minute
Mean	66	75	80	73
SD	7	8	10	10

Percent of individual maximal heart rate during intervention period
	Week 2	Week 7	Week 12
Mean	71	71	78
SD	11	9	8

Percent in intensity zones
	>70% HRmax	70–80% HRmax	80–90% HRmax	90–100% HRmax
Mean	61	32	22	8
SD	30	18	16	11

Figure 2. a–f: Individual exercise intensities during training sessions.

HRmax, heart rate maximum; ID, identification.

There was no statistical change from baseline to 12 weeks for HbA1c (p=0.14), VO2peak (p=0.4) or physical (p=0.11), and mental health (p=0.48). From baseline to follow-up there was a small increase in total cholesterol (p=0.09) mediated by an increase in LDL (p=0.02). There was a drop in body fat mass (p=0.04) and BMI (0.02) but no change in visceral fat (p=0.24). We found no change in systolic blood (p=0.54) pressure but a significant drop in diastolic (p=0.04) blood pressure. Lastly there were no changes in the participant’s physical activity levels (p=0.45) but higher levels of engagement in beneficial behaviors (p=0.03). All baseline to 12-week measures are displayed in Table 4.

Table 4. Change from baseline to 12-week.

Variable	Baseline median	Min/max	12-week median	Min/max	p-value
HbA1c (mmol/mol)	49.5	40.0–74.0	48.5	38–67	0.14
VO₂peak (mL/min/k)	1.9	1.0–4.1	2.0	1.1–3.9	0.40
PCSc	44.8	32.3–54.4	46.2	39.–5.2	0.11
MCSc	58.2	33.1–62.2	59.5	25.–64.1	0.48
Total cholesterol (mmol/L)	3.9	2.6–6.0	4.3	2.6–6.2	0.09
LDL (mmol/L)	1.5	0.4–3.6	2.0	0.8–4.0	0.02
HDL (mmol/L)	1.2	0.9–1.6	1.3	1.0–1.8	0.30
BMI (kg/m²)	27.5	23.5–33.9	26.9	22.8–33.7	0.02
Body fat mass (kg)	37.5	20.5–43.7	35.9	17.9–42.8	0.04
Hip/waist ratio	0.98	0.84–1.09	0.95	0.84–1.06	0.24
Systolic blood pressure (mmHg)	126.5	112.0–114.0	123.5	116.0–137.0	0.54
Diastolic blood pressure (mmHg)	79.5	71–97	78	68–89	0.04
DIAB-Q	75.2	68.1–89.9	71.4	58.2–87.4	0.03
PAS2	38.7	36.4–47.0	39.1	35.9–46.8	0.48

No serious adverse events were detected. Two times a participant fell involuntarily during the training session but continued and finalized the sessions. One participant experienced a muscle strain and resumed handball training after a one-week rest period. There were no episodes with exercise induced hypoglycemia.

Discussion

Recreational HBT was found feasible for people diagnosed with T2DM with high attendance rate and moderate to high exercise intensities. The HR recordings showed an average HR of 73% (SD 10.2) and almost 30% of the time with an HR above 80% of HRmax. These values are in line with those found in non-clinical inactive postmenopausal women playing recreational handball by Pereira et al.²¹ They reported a mean HRmax at 76% (SD 6), however duration above 80% of HRmax at 44% (SD 20) of the time which is higher than those found in the present study. This may be explained by the differences between the interventions, as they only measured exercise intensities during small-sided matches.²¹ The last part of the present intervention did produce the highest exercise intensities among the participants with a mean HR at almost 80% of HRmax and more than 45% (SD 37) of the time intensities above 80% of HRmax. Andersen et al.²⁶ reported mean intensities at 82% of HRmax and almost 65% of total playing time with intensities above 80% of HRmax, among men diagnosed with T2DM playing small-sided football. The explanation for this may be that their participants were younger (mean 50.6, SD 7.1) compared to the present study and that they excluded people with co-morbidities and diabetic complaints that might reduce the potential of playing football with high intensities.²⁶

The present study was not powered to detect significant changes in effects. However, there was a tendency towards improvement in most of the outcomes assessed. Previous studies investigating football in women and men with T2DM reported improvements of 10% after 12 and 24 weeks in VO₂peak²⁶^,²⁷ working at similar exercise intensities as in the present study. Similar results are found in studies investigating recreational handball in different populations¹⁶^,²¹^,²⁸ suggesting that HBT for people with T2DM may be an effective way to improve cardiovascular function. The potential effect of recreational team sport in reducing HbA1c is under-investigated, however, exercise in general especially with higher intensities has been found to substantially decrease HbA1c levels in people with T2DM.²⁹ Furthermore, team sport has been found effective to increase the quality of life and instinct motivation,³⁰^,³¹ which are important predictor of long-term adherence and fidelity.¹¹

No serious adverse events occurred during the handball-based training which is in concordance with previous studies.¹⁷^,²⁰^,²¹ Only one case of muscle injury happened and was managed conservatively. Few episodes with involuntary falls occurred, however, these falls did not cause any injury that prevented the participants from continuing the training. These falls may be a source of great concern and the presence of diabetes complications such as retinopathy and neuropathy may place people with T2DM at a greater risk of falling. Compared to non-clinical populations engaging in handball training, the present study did not report more cases of adverse events.¹⁷^,²⁰^,²¹ This may be explained by the difference in the intervention as former study interventions only include small-sided matches, which only represented the last third part of present HBT. Furthermore, the present intervention included 20 minutes of warm-up comprising running, strength training, coordination exercises, balance training, and flexibility exercises followed by 20 minutes of handball skill training, which may reduce the risk of adverse events occurring during matches.

Limitations and strengths

Some deviations from the registration in ClinicalTrials.gov were made. Since the current trial is a feasibility trial, we changed our primary outcomes reported in ClinicalTrials.gov to feasibility outcomes and listed all effectiveness outcomes as secondary outcomes. Furthermore, we planned an aerobic endurance test, however this test was not completed as it was too demanding according to the participants’ physical condition.

The recruitment rate was lower than expected and there was a possibility of selection bias, as the present study appealed to participants motivated for handball. Participants were asked to stay on their current medical prescription and change in medicine may affect some outcome of interest. When reporting exercise intensities in warm-up, handball-specific exercises, and small-sided matches the categorization may not represent the actual content of the training session due to the pragmatic delivery of the intervention. Consequently, some overlap between the three parts is expected to be present. All assessments were pre-defined and the assessment of clinically relevant outcomes was conducted using validated instruments.

Perspectives

For patients with T2DM, adherence and fidelity to prescribed exercise are highly important. In the present study we observed a high attendance rate (>80%) and clinically relevant training intensities. Additionally, it is notable that HBT can be played without prior experience with handball and can be played with a limited number of participants. Furthermore, small-sided matches were played at a 13×20 meters indoor court which allows three of these to fit on a regular handball court, and thereby the possibility of triple the number of participants. Thus, HBT may be attractive and easily accessible for people with T2DM. The present study’s feasibility findings and preliminary results indicate that future studies need to investigate the efficacy and effectiveness of HBT for people with T2DM in randomized controlled designs.

Conclusion

HBT was feasible for people with T2DM. The present study observed a high attendance rate of 83% and a mean training intensity of almost 75% of HRmax. More than 60% of the time participant trained with an intensity of 70-100% of HRmax. The highest training intensity was found during small-sided matches, with a mean at 80% of HRmax. Future randomized controlled trials are needed to determine the effect of HBT.

Author contributions

Martin Færch Andersen: Conceptualization, methodological inputs, project administration, intervention delivery, data collection, formal analysis, funding acquisition, writing the first draft, commenting in rounds of revision (lead), approved the final draft.

Allan Riis: conceptualization, methodological inputs, writing the first draft, commenting in rounds of revision, approved the final draft.

Henrik Foged Borup: Intervention delivery, methodological inputs, commenting in rounds of revision, approved the final version.

Astrid Dall: Intervention delivery, methodological inputs, commenting in rounds of revision, approved the final version.

Mie Torp: Intervention delivery, methodological inputs, commenting in rounds of revision, approved the final version.

Rikke Hareskov Elversøe: Intervention delivery, methodological inputs, commenting in rounds of revision, approved the final version.

Janus Laust Thomsen: Methodological inputs, oversighting test procedures, commenting in rounds of revision, approved the final version.

Peter Vestergaard: Methodological inputs, commenting in rounds of revisions, approved the final draft.

Anne-Mette Lücke Dissing: Conceptualization, Methodological inputs, Data collection (lead), Formal analysis, commenting in rounds of revisions, approved the final draft.

Data availability

Underlying data

Open Science Framework: Data repository: Recreational handball-based training for people with type 2 diabetes. https://doi.org/10.17605/OSF.IO/VZ6G5.³²

This project contains the following underlying data:

• dataset_pub.xlsx (Sheet 1, attendance: Individual participant (ID) attendance in two weekly training sessions for twelve weeks. X marks when participants attended a training session. Sheet 2-7, exercise intensity: Individual participant (ID) exercise intensity at both training sessions in week 2,7 and 12. First row indicate time (minutes), first column indicates participant (ID), data is reported as percentage of individual heart rate maximum.)

Reporting guidelines

Open Science Framework: CONSORT extension for pilot and feasibility trials for ‘Recreational handball-based training for people with type 2 diabetes: a feasibility trial’. https://doi.org/10.17605/OSF.IO/VZ6G5.³²

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Acknowledgements

We thank Vibeke Brinkmann Løite for her methodological contributions when planning this study.

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