# HbA1c - How Low Is Too Low?



## TheClockworkDodo (Sep 13, 2015)

My HbA1c was 103 when I was first diagnosed (and hospitalised with DKA), was down to 50 six months later, hovered around 45-50 for the next three years, and then earlier this year it was 42.

The results print-out from my hospital stay said that normal levels are 30-45, so when I got the result of 42 I was really pleased.  But the DSN at my new surgery (I moved last year) says it's too low, shows I have a lot of hypos, and should be a bit higher.

Well, I do have a lot of hypos, but if normal is 30-45 then surely 42 is on the high side of good, not the low side   Am I missing something?


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## Northerner (Sep 13, 2015)

Some healthcare professionals get their knickers in a twist if someone comes in with a 'normal' HbA!c if they are on insulin - they think we must be constantly plummeting down into near-coma hypos because no-one can have that good control! I get it all the time, because my HbA1c has been in the 31-41 range (5%-6%) practically since I was diagnosed 7 years ago. On the other hand, they want you to achieve tight control that, as you say, brings you as close as possible to non-diabetic range! 42 is excellent, well done!

Yes, I have hypos, I think they are almost inevitable with tight control and using tools as clumsy as insulin injections and meter readings (or even with pumps and CGMs, although their advanced finesse does help enormously). The main point is, how low those hypos are, do you get symptoms at a sufficiently high level so they can be easily acted upon? I get a lot of mid- to high-3s but I have always been able to deal with them promptly. I've had a few (but only a very small handful of bad lows, but totally unpredictable and difficult simply because my levels were falling so fast without explanation.

The variables are simply too large to make anything more than an educated guess each time you inject. You can have the same food, at the same time, the same insulin dose and end up with an unexpected low one day and an elevated level the next. It's like walking a tightrope juggling cats! 

The only alternative is to deliberately keep your levels on the high side. However, this then runs the chronic risk of quite horrifying complications over the longer term. I'm one of those people who is more averse to these complications than things happening occasionally that I can easily deal with. The problem with scaring people about perfectly manageable hypos is that they then become terrified of them and avoid them at all costs, and it is the attitude of your DSN that may be the cause of this overreaction, in my opinion.

Hypos aren't pleasant, but it's one of those risk assessments you have to make in life. I think that as long as you have good hypo awareness (especially if you drive - I don't), and the hypos are not frequently too low (in which case you use your experience to adjust your parameters, usually insulin) then they're not a problem. My consultant knows I know what I am doing and no longer questions my numbers, but the nurse does


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## Robin (Sep 13, 2015)

My DSN has obviously been trained that all hypos are evil. Every time I see her, she congratulates me on my HbA1c, which is usually between 6.9 and 7.1 (that converts to about 53, I think, a tad too high for my liking) and then adds in a panicky tone,'but you don't have hypos do you?' and when I say, yes of course I do, looks like she's about to pass out!
Since getting the Libre, I've started doing mealtime injections half an hour before I eat, because I realised I was spiking whatever I ate, when I  did them at the time of eating. I'm hoping this has lowered me a few points, and I'm just trying to picture my DSns face when she's torn between congratulations, and a telling off for the inevitable hypos I 'must' be having.


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## KookyCat (Sep 13, 2015)

Mine is usually between 39 and 42 and I get the hypo horror face when they identify even a high three in my blood sugar diary.  I say as long as you're not having crashing hypos every five minutes then it's not too low . I don't have major hypos (now my nighttime hypo problem with Lantus has been removed), have good hypo awareness and work hard (very hard) to keep my HBA1C that low, and I intend to keep it that way for as long as possible.  Personally I think it's nigh on impossible to achieve a good HBA1C without the occasional hypo.  I wouldn't be happy with anything higher than 45 personally, but it's all about what gives the best quality of life and keeps you safe so a very personal choice I think


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## Matt Cycle (Sep 13, 2015)

This seems to be a common theme as my DN congratulated me on my HbA1c last December of 56 but said "you're not getting too many hypos are you?"  The one from this June was 49 and I got the same hypo question.  I think she realises that after all these years of being diabetic I'm reasonably capable of managing it.  I'm still trying to get mine lower though.


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## TheClockworkDodo (Sep 13, 2015)

Thank you both for your replies - reassuring to know it's not just me   - especially as another nurse (not a DSN) looked at my 42 and said "That's way too low - are you even diabetic?!" which I thought was weird, because if I'm managing my diabetes properly, surely my HbA1c ought to be the same as that of a healthy person - so I was starting to wonder whether the healthy range I'd got of 30-45 was right 



Northerner said:


> I get a lot of mid- to high-3s but I have always been able to deal with them promptly. I've had a few (but only a very small handful of bad lows, but totally unpredictable and difficult simply because my levels were falling so fast without explanation.



Snap!



Northerner said:


> The variables are simply too large to make anything more than an educated guess each time you inject. You can have the same food, at the same time, the same insulin dose and end up with an unexpected low one day and an elevated level the next.



And snap again!  4 hours after dinner one day I have a reading of 5, eat 2 ryvita, go to bed, and wake up with a reading of 8; next day 4 hours after dinner I have a reading of 5, eat 2 ryvita, go to bed, and wake up with a reading of 3.  I have asked about this and both consultants & DSNs are completely clueless about what might cause the difference.



Northerner said:


> The only alternative is to deliberately keep your levels on the high side. However, this then runs the chronic risk of quite horrifying complications over the longer term. I'm one of those people who is more averse to these complications than things happening occasionally that I can easily deal with.



And that's what I've always thought too - I'd much rather deal with frequent hypos than run the risk of nasty complications (though DSN did say having lots of hypos can lead to complications too, because they put a strain on our bodies).  But most of the time I'm aware when I'm getting hypo, and I don't drive either.

Robin - that is interesting about the delayed reaction you get to insulin, because I get a delayed reaction to everything - insulin, food, exercise, and so on.  It makes it very difficult to plan - if I do something like gardening in the morning I can still have a high reading at lunchtime and then the hypo for doing too much gardening can arrive late afternoon ..


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## TheClockworkDodo (Sep 13, 2015)

Thanks KookyCat and Matt - glad to hear this seems to be a common theme!

KookyCat - what was your night-time hypo problem with Lantus?  I had one too - when I came out of hospital I was put on 16 units of Lantus every evening - and I hypo'd every night and had to get up and eat jam sandwiches in the night to get my BGL back up to 4 by morning - when I went back for first outpatients appointment, they cut my dose to 6 units!


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## KookyCat (Sep 14, 2015)

TheClockworkDodo said:


> Thanks KookyCat and Matt - glad to hear this seems to be a common theme!
> 
> KookyCat - what was your night-time hypo problem with Lantus?  I had one too - when I came out of hospital I was put on 16 units of Lantus every evening - and I hypo'd every night and had to get up and eat jam sandwiches in the night to get my BGL back up to 4 by morning - when I went back for first outpatients appointment, they cut my dose to 6 units!



Mine was similar, but they initially gave me 30 units to take at night   I gradually reduced it down to 16 and switched it to mornings because I didn't get a wink of sleep and a CGM showed it was because I was going hypo pretty much all night, then rebounding.  To cut a long story short I got it down to 10 units but was still waking up drenched in sweat every night, even though ten units wasn't keeping me tremendously stable during the day.  Everyone got a bit freaked out when the third CGM proved what I already knew, I don't wake up when hypo, I only wake up when my liver compensates and my blood sugar starts to rise (and on two of the nights my blood sugar had gone below 1.8).  I switched to Tresiba in June and it's a totally different experience, I take 7 units and haven't had much in the way of night time hypos since (1 or 2 hypo drenches), have weirdly had more minor daytime hypos (high 3's mostly) but it feels more normal most of the time, and I've actually been able to put a few pounds on which is good.  In retrospect I now think Lantus had always been giving me pretty bad hypos which is why I felt so dreadful most of the time, but because I seem to need more background insulin during the day they were hidden over night.  All my daytime hypos happen at around 2pm, which fits with what I've realised is the start of the downturn in my background needs, so I'm working on the best way to address that.  Most of the time I eat lunch and under bolus to accommodate that but it means that I then have to eat to a timetable.  Ooh it's such fun this diabetes lark


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## everydayupsanddowns (Sep 14, 2015)

I think this is the ultimate 'cat juggling tightrope walker' question. (Thanks Northie, I *love* that image)

Most T1 specialists accept that *some* hypoglycaemia is an inevitable consequence of intensive insulin therapy. And you are not necessarily immune from hypos even if you run much higher than is recommended most of the time.

So it becomes a balancing act, where you have to guess whether your 'some' is the same as someone else's 'some', and also to make sure that your own 'some' is as low as you can get it and is at a level that is a) safe b) not gradually creeping up and c) worth it based on guesses as to long-term outcomes that you cannot possibly predict.

Lower A1cs are known to associate very strongly with fewer long term complications. But as always _it's not as simple as that_ and two people with identical BG profiles and A1cs are not necessarily as likely (or not) to get any D nasties.

What is a hypo anyway? What do they mean by it? Below 4? Below 3.9 (US), Below 3.5 or 3.0 (clamp studies show brain affected). 'Four is the floor' is a really useful guide, but there is some debate as to whether that counts as hypo or whether you are treating to *avoid* hypoglycaemia at 4. Non-Ds can quite easily reach down to 3.8 without symptoms and no-one bats an eye (because they have *far* more finely tuned correction systems).

However - and this is *incredibly important *- Low blood glucose causes a significant surge of hormones and 'emergency' responses. The brain knows it is being put in a potentially dangerous position so it takes action. It begins to adapt. With each event (even quite mild ones) it makes measurable physiological changes so that it can operate better at lower levels. It learns to cope better next time. 

The more you have and the longer they last, the less you will feel them. And the less you feel them the more exposed to them you can be and the fewer you will catch early. Like Kookycat overnight are a particular fave of mine. Libre sensors have shown that I can spend hours and hours low overnight with absolutely no indication other than low BG at breakfast time.

And once your warning signs have taken a bit of a knock and you develop Impaired Awareness of Hypoglycaemia (which for my own purposes I consider not spotting until into the low 3s) you are 6x more likely to experience Severe Hypoglycaemia. And 2 SH a year will cost you your driving license (along with an awful lot of strife for you and your family).

Looking back I can see that I had years of pretty bad IAH and SH (before I found forums etc) and while I have gone along way to improve things and my awareness is _massively_ improved over what it was I recognise that I still do have a degree of unawareness and I have to be really careful to try to keep the number of dips below 4 to an absolute minimum.


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## shirley (Sep 14, 2015)

My son's last HbA1C was 39 and my Consultant now agrees that that is quite correct and that I am not wrong in trying to keep his levels as low.    My son has no awareness, low or high so we have the Libre so that we (and others) can keep a close eye on things.   

On one previous appointment, a different Consultant was horrified that we had recorded lows of 3.9 and so on but I feel that this is pretty inevitable from time to time and however careful we are about the amount of insulin we inject, the food he eats, we don't always know what activities he will be doing and how his body will respond.   I have therefore stopped beating myself up about this but obviously try to avoid lows (and highs) whenever possible.

Things have improved a lot since moving from twice daily injections, to Lantus and very quickly to Tresiba which is certainly protecting against some of the overnight lows that the Libre was recording and has thankfully meant that I have less overnight checks to do.


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## stephknits (Sep 14, 2015)

mine is the same as Shirley's son - 39 (5.7).  I have had various responses from people in the medical profession - from that is too low and you must be having frequent daily hypos and have poor hypo awareness (i don't, like everyone I have the odd one - impossible not to!).  My hospital DSN says she is perfectly happy with it.  
As it is our condition that we have to manage, it is down to us to best cope with the juggling act.  for me that is keeping my HbA1c as low as possible whilst trying to stay safe.


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## heasandford (Sep 14, 2015)

This has been a very useful post, and I do think our moderators do a particularly good job of gently balancing the evidence!

The LIbre has proved to me that I am every bit as unstable (when eating anything!) as I thought I was, so chasing highs and lows is a continual effort.  This has helped me put into perspective the importance of watching those lows versus keeping down the HbA1c. Thanks!


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## DeusXM (Sep 14, 2015)

Mike is bang on.

It's a fine balance as yes, too many hypos is a major problem and should not be part of achieving a 'good' A1C.

The other side is that, depending on the healthcare professional you deal with, a hypo ranges from a mild inconvenience (which is probably how most of us see them) to the absolute worst thing that could possibly happen to you (which seems to be the view of most health care professionals).

You can't blame docs and nurses for taking the view they do. A hypo in principle is a serious medical emergency - your brain literally stops working properly and you are at risk of an accident or death. Plus, a cynic would also say that a hypo can be quite immediately fatal and leave a fairly short paper trail that can lead back to a healthcare professional's advice. The consequences of long-term high blood sugar take a lot longer to kick in, by which point whoever was caring for you has either retired or moved on, and there also isn't quite such an easily attributable trail leading back to anyone anyway.

What we all need to do is aim for the lowest A1C we can without having too many hypos and be able to prove that to doctors/nurses etc. It's the only way we're going to break the conventional wisdom (formed when we had just two kinds of insulin) that a healthy A1C does not mean hypos all the time. It might also be worth introducing your care team to the wonders of standard deviation - for instance, an A1C of 6.5% with fairly steady BGs throughout the day is probably better for your health than an A1C of 5.5% where you're yo-yoing all over place. A1Cs as an average can't actually tell the tale of what your control is like. 

If you think about it, it's really cock-eyed, isn't it? We're told off when our A1Cs are higher than non-D ones, yet the moment we get a non-D A1C, we're told it's too low!


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## TheClockworkDodo (Sep 15, 2015)

Thanks everyone for your replies - it's been really interesting, and also reassuring to know I'm not the only one who is doing the tightrope act with this 

I think Steph has summed up very well what I feel about it, now I know my results are "normal":



stephknits said:


> As it is our condition that we have to manage, it is down to us to best cope with the juggling act.  for me that is keeping my HbA1c as low as possible whilst trying to stay safe.




I've only had one really bad hypo when I didn't know what was going on and my partner had to bring me my blood sugar stuff and make me eat glucose.  Apart from that I'm always aware of my hypos, and most of them feel pretty trivial, in the high 3s.

I do seem to wake up if I hypo in the night - in fact I wake up with a real jolt and sit straight up, which I can't normally do, so I think night-time hypos must give me a bit of an adrenalin rush.  I rarely get them now I've sorted the problem with too much Lantus.  Of course it's entirely possible I only get this jolt if my BGL's really plummeting, and that on other nights it's gradually going low overnight without waking me up, but unless I can get hold of a CGM I won't be able to tell, so there seems little point worrying about it.

Anyway, I saw diabetes consultant yesterday for my annual review, and my HbA1c is up to 48 - I was disappointed, he was pleased!   He thinks my control is "too tight", which strikes me as a contradiction in terms!  I asked him about CGM, but despite his horror over my frequent hypos he didn't seem to think it was feasible - not because of cost, just because they don't have enough devices.  I haven't seen him before though (that makes 7 different diabetes consultants in 4.5 years!) so didn't want to press him, so will try again next time or ask DSN next time I see her.

But my other results were fine, he said my kidneys are "fantastic"  and my thryoid results, which were borderline hypothyroid, are now in normal range, which is a huge relief, so overall I'm pleased


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## JanieB (Jan 14, 2016)

I had my first Hba1C result this week ( having being diagnosed, at age 54,  with Type 1 in August ). I  was thrilled to learn it was 43 ( 6.1%) but really frustrated by the nurse's response that it was too low and indicates hypos: the lowest I have been in the past 3 months is 4.6, twice ( and I could feel it!). My diet is low carb and I exercise regularly  to keep my blood sugar levels in the 5.0 - 9.0 range. I can feel when I drop below 5.5 and usually eat something to bring me back up to around 7  The nurse said she wanted to see more higher numbers. I've been refused the 'structured education' course as my hospital don't let you go until you have had diabetes for a year. So, I'm told not to go too high or too low, told not to use too much insulin, told to eat more starchy carbohydrate, not allowed to go on the course that teaches me how to manage this disease  and then told off for achieving steady and fairly stable blood sugar that are almost in the 'normal' range! Thank goodness for the internet and the accessibility to recent and relevant research!


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## Northerner (Jan 14, 2016)

JanieB said:


> I had my first Hba1C result this week ( having being diagnosed, at age 54,  with Type 1 in August ). I  was thrilled to learn it was 43 ( 6.1%) but really frustrated by the nurse's response that it was too low and indicates hypos: the lowest I have been in the past 3 months is 4.6, twice ( and I could feel it!). My diet is low carb and I exercise regularly  to keep my blood sugar levels in the 5.0 - 9.0 range. I can feel when I drop below 5.5 and usually eat something to bring me back up to around 7  The nurse said she wanted to see more higher numbers. I've been refused the 'structured education' course as my hospital don't let you go until you have had diabetes for a year. So, I'm told not to go too high or too low, told not to use too much insulin, told to eat more starchy carbohydrate, not allowed to go on the course that teaches me how to manage this disease  and then told off for achieving steady and fairly stable blood sugar that are almost in the 'normal' range! Thank goodness for the internet and the accessibility to recent and relevant research!


For goodness sake!  Sounds to me like you are doing an absolutely sterling job without their courses or advice! Ignore their nonsense!


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## pottersusan (Jan 14, 2016)

Northerner said:


> Ignore their nonsense!



Sounds like the best advice. As you know I'm a real lover of the 'experts' . I'm going to meet my new surgery DSN tomorrow - that'll be interesting!


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## KookyCat (Jan 14, 2016)

I wonder why you have to wait twelve months before going on a course....is there a warranty nobody told me about?  Can we return the diabetes within 12 months if we're not happy with it?  I can't believe my lot didn't tell me that, mine's been faulty from the start 

Well done on the hba1c and good work for getting it so stable


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## pav (Jan 14, 2016)

I was a lot happier when I was hovering just above the hypo level, but the DN insisted that I run higher. I did have hypos, but the pain was barely noticeable and more importantly I was stable ish within a range I was happy with. Years later i am in more pain levels are stable to what the DN wants but not for me as I run in the teens. Now the DN said no point in doing a hba1c test just yet as we know the results will come back high.

Meds changed again back to a med I can't tolerate, hba1c to be done in March to see what its like. Been trying to get onto injectable's so I can have more control, but keep getting refused.


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## trophywench (Jan 14, 2016)

Well the 12 months is mainly to eliminate those in their honeymoon period, cos if your pancreas is still constantly chipping in unpredictably, you can't really either basal test or dafne with any reliability, can you?

And they are usually oversubscribed anyway - there aren't sufficient DSNs to run enough courses and do the rest of their work as well, cos there are too many of us! - consequently there is always a wait anyway.

Coming back to your 'too low' A1c - did you show her your meter so she could see with no argument that you were telling the truth?


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## KookyCat (Jan 15, 2016)

Actually should have asked this first, is the nurse a hospital DSN or a nurse at the GP surgery?  I find there's generally a difference in the quality of advice.  My DSN at the hospital clinic is great and not prone to panic about hypos.  The nurses at the GP surgery are great but very honest about their lack of experience with type 1 and they get a bit panicky about hypos.

In terms of structured education the twelve month rule doesn't apply here, but if they must stick to their nonsense rules ask about one to one education as an interim.  My clinic do both, one to one sessions if a course isn't running immediately and then structured courses later.  I understand what TW is saying about honeymoon periods but I don't think it's acceptable to provide no education at the very time when you probably need more help.  A "helpful" pancreas can actually be very difficult to handle and so they should be more forthcoming with advice.

Also if any of them can tell me how you maintain a hba1c at the recommended level without the occasional hypo I'll give em a meddle


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## Northerner (Jan 15, 2016)

I had my diabetes education course about two months after diagnosis and found it very helpful


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## Bloden (Jan 15, 2016)

A 12-month rule? Even if you can't apply what you've learnt, because you're still on honeymoon, you can start practising, surely? Start as you mean to go on...


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## everydayupsanddowns (Jan 15, 2016)

I'm pretty sure the research says 'the earlier the better'. Can't remember what the NICE guidance says, but I think it was within 6 months. There may even have been some evidence of long-term gain if levels better controlled from the off (beta cell function) - but I might be getting confused with T2 stuff I have been reading!


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## JanieB (Jan 15, 2016)

trophywench said:


> Well the 12 months is mainly to eliminate those in their honeymoon period, cos if your pancreas is still constantly chipping in unpredictably, you can't really either basal test or dafne with any reliability, can you?
> 
> And they are usually oversubscribed anyway - there aren't sufficient DSNs to run enough courses and do the rest of their work as well, cos there are too many of us! - consequently there is always a wait anyway.
> 
> Coming back to your 'too low' A1c - did you show her your meter so she could see with no argument that you were telling the truth?


No, I showed her my ( very detailed) diary which every time she sees she complains about my numbers being "too perfect" and tells me I'm trying too hard. Thought I might try down loading the info onto my computer and generating some graphs to show her the range of readings next time.


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## Northerner (Jan 15, 2016)

JanieB said:


> No, I showed her my ( very detailed) diary which every time she sees she complains about my numbers being "too perfect" and tells me I'm trying too hard. Thought I might try down loading the info onto my computer and generating some graphs to show her the range of readings next time.


Hmm...how 'encouraging' of her - not!  Good control is always hard to achieve, but it is well worth trying your hardest to get there, for the consequnces of 'taking it easier' - as she would have you do - are potentially very unpleasant to say the least. I'm afraid I would ignore someone who spoke like that to me, as their opinion is not worth having. Sounds to me like you are doing the right thing, so keep up the good work!


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## shirley (Jan 15, 2016)

When I took my son to see our Consultant last week I already knew that his HbA1C was 5.4% and expected some criticism.  I pointed out, before he could get a word in edgeways, that my aim is to keep within range as much as possible to avoid all of the problems that he would otherwise develop and that heaven knows he has enough to contend with anyway. I said that I was able to achieve this for him by having the right insulin and my trusty Freestyle Libre which means that although he goes a bit low, we can always deal with it (apart from sometimes in the night which I have commented on and had good advice from here).   He didn't say anything critical, just well done and told me to tell our practice nurse, who I was seeing two days later, that he was very happy, just in case she was critical.  As it happens, she was very supportive too and said we had the best results of any of her type 1's.  I don't strive to get the best results, just to do whatever possible to keep him safe and healthy.   It is so hard a lot of the time, I didn't mention to him that I had learned very little from him and the NHS and everything from this forum.


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