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ati
o
n
a
l
Jo
urn
a
l
o
f
P
u
b
lic Hea
l
th Science (IJ
P
HS)
Vol
.
4,
N
o
.
4
,
D
ecem
b
er 20
1
5
, pp
. 30
4~
30
9
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: 225
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urn
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o
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ttp
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r
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e
x.ph
p
/
IJPHS
Serum Level Changes of Neur
otrophin-3 after Performing
Diabetic Foot Exercise
in Diabetic Neuropathy
Tri Wa
hy
uliati
1
, A
g
un
g Pr
a
n
ot
o
2
, Sa
mekto
W
i
bo
wo
3
1
Department of Neurolog
y
,
Muh
a
mmadiy
a
h
University
of
Yog
y
akarta, Indon
esia
2
Department
of I
n
ternal Medicin
e
, Airlangga Univ
ersity
, Indonesia
3
Department of Neurolog
y
,
G
a
dj
ah Mada Univer
sity
, Indon
esia
Article Info
A
B
STRAC
T
Article histo
r
y:
Received Aug 15, 2015
Rev
i
sed
O
c
t 25
, 20
15
Accepted Nov 28, 2015
The res
earch
ai
m
e
d to det
e
rm
ine the
pa
ttern of
changes in
seru
m levels of
NT-3 in the improvement of diabetic
neuropath
y
,
after doing d
i
abetic foot
exercise. A tru
e
experimental stu
d
y
w
ith
randomaized pre – post
test con
t
ro
l
trial. A total of
36 subjects meeting th
e
inclusion
and exclusion criter
i
a wer
e
includ
ed in
the exer
cise grou
p or th
e
contr
o
l one with
age match
e
d
s
y
stematic rand
om sampling
method.
Exer
cise group had
a significan
t
improvement on the scor
e of
ABI (
p
.0.002)
, s
y
sto
lic bloo
d pressure
(
p
.0.014)
, diasto
lic blood pr
essure (
p
.0.055)
, D
N
S (
p
.0.01), D
N
E (
p
.0
.001)
and incr
eas
ed
o
f
s
e
rum
level
o
f
NT-3 (
p
.0
.049
). Control group
had result
res
p
ect
ivel
y on
ABI (
p
.0.131), s
y
stolic blood pressure (
p
.0.668
), diastolic
blood pressure (
p
.0.216)
, DNS (
p
.1.00)
, D
N
E
(
p
.0.543), and in
cr
ease of NT-
3 (
p
.0.264)
. Th
e comparation r
e
sults of the tw
o groups had a significant
differen
t
on th
e score of ABI
(
p
.0.01)
, s
y
sto
l
ic blood pressur
e
(
p
.0
.01),
diastolic blood
p
r
essure (
p
.0.01
)
, D
N
S
(
p
.0.01), D
N
E (
p
.0.01)
, and
incre
a
s
e
d
of NT-3 (
p
.0
.01)
. Diab
etic foot exercise had
a per
i
pheral aff
e
ct on
a clinically
significant improvement ba
sed on ABI scores,
s
y
stolic and diastolic bloo
d
pressure, DNS and DNE,
and
increase o
f
serum level of
NT-3.
Keyword:
Diabetes
Exercise
Foot
N
e
uro
p
a
t
h
y
N
e
uro
t
r
oph
in-3
Copyright ©
201
5 Institut
e
o
f
Ad
vanced
Engin
eer
ing and S
c
i
e
nce.
All rights re
se
rve
d
.
Co
rresp
ond
i
ng
Autho
r
:
Tri W
a
h
y
u
liati
Depa
rt
m
e
nt
of
Neu
r
ol
o
g
y
Uni
v
ersi
t
a
s M
uham
m
adi
y
ah Yo
gy
aka
r
t
a
,
In
do
nesi
a
Em
a
il: tri.wahyu
liati@yah
o
o
.co
m
1.
INTRODUCTION
Diab
etes m
e
lli
tu
s (DM) is
on
e
o
f
t
h
e m
a
j
o
r
p
r
ob
lem
s
fo
r
hu
m
a
n
h
ealth
in
th
e 21
st
cen
tury. Th
e
World
Health
Org
a
n
i
zatio
n
(WHO)
p
r
ed
icts th
e
m
o
re in
cr
easi
n
g n
u
m
b
er of
peo
p
l
e
w
ith diabetes in
various
co
un
tr
ies in
clud
ing
I
ndo
n
e
sia [1
]-
[3
].
Sin
ce th
e d
i
sco
v
e
ry o
f
in
su
lin
, d
i
ab
etes co
m
p
lica
tio
ns h
a
v
e
sh
ifted
fro
m
acu
te
to
ch
ron
i
c
com
p
l
i
cat
i
ons nam
e
ly
m
acroangi
opat
h
y
,
m
i
croa
n
g
i
o
pat
h
y
and
di
abet
i
c
n
e
ur
o
p
at
hy
.
Di
abet
i
c
neu
r
opat
h
y
i
s
a
gr
o
up
of
p
r
o
g
ressi
ve
dege
nerat
i
v
e
di
sea
s
es i
n
v
o
l
v
i
n
g
t
h
e pe
ri
p
h
er
al
ner
v
o
u
s sy
st
em
due t
o
DM
. It
s
pre
v
al
ence r
a
n
g
es fr
om
20% - 62
% am
ong vari
ous c
o
u
n
t
r
i
e
s. In I
n
do
nesi
a, t
h
e dat
a
an
d
i
n
fo
rm
ati
on cent
e
r
s
o
f
th
e Basic H
ealth
Research
du
r
i
ng
2011
in
fo
r
m
ed
th
at d
i
ab
etic n
e
u
r
op
ath
y
af
f
e
cts
m
o
r
e
th
an
5
0
% of
di
abet
i
c
pat
i
e
n
t
s wi
t
h
am
put
a
t
i
on
num
bers
r
a
ngi
ng
f
r
om
1
5
-
3
0%.
I
n
C
i
pt
o m
a
ngu
n
k
u
s
u
m
o Hospi
t
a
l
J
a
kart
a
(W
est J
a
va
–
Indonesia), in
2007, this am
putation fi
gures
reached 35
%
with an i
n
crease
of
54%
by
2011. In
Sur
a
bay
a
(
E
ast
Java –
I
n
d
o
n
e
s
i
a
), 5
1
%
pat
i
e
nt
s wi
t
h
di
ab
et
es expe
ri
enc
e
d pe
ri
p
h
eral
neu
r
opat
h
y
w
h
o we
re
fo
u
nd i
n
t
h
e
o
u
t
p
at
i
e
nt
depa
r
t
m
e
nt
of
pol
y
c
l
i
n
i
c
fo
r di
a
b
e
t
es of
Dr
. S
o
e
t
om
o General
Hos
p
i
t
a
l
Su
ra
b
a
y
a
.
M
o
re
ove
r, i
n
t
h
e i
n
pat
i
e
nt
de
part
m
e
nt
of i
n
t
e
rnal
m
e
di
ci
ne di
vi
si
o
n
,
i
t
wa
s n
o
t
e
d t
h
at
9
0
.
0
3
%
of
ne
ur
o
p
at
hy
i
n
di
abet
es pat
i
ent
s
was wi
t
h
com
p
l
i
c
at
i
ons
of di
abet
i
c
f
o
ot
. These
great
pro
b
l
e
m
s
l
e
d
t
o
a hi
gh n
u
m
b
er o
f
d
i
sab
ilities,
d
e
clin
in
g
produ
ctiv
ity
an
d
hu
ge co
sts [1
]-[3
]
.
Eff
o
rt
s i
n
p
r
e
v
ent
i
n
g t
h
e di
sease have
be
en co
nd
uct
e
d
.
Ind
o
n
esi
a
n S
o
ci
et
y
of En
d
o
cri
nol
ogy
(PERKENI) in 20
11
C
o
n
s
en
su
s Man
a
g
e
m
e
n
t
and Prev
en
tio
n
of
Diab
etes Mellitu
s Type 2 in
Indo
n
e
sia h
a
d
Evaluation Warning : The document was created with Spire.PDF for Python.
I
J
PH
S I
S
SN
:
225
2-8
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6
Ser
u
m
Level C
h
anges
of Neut
rophi
n
-3 After
Perfor
ming
Diabetic F
o
ot Ex
ercise in
.... (Tri Wahyuliati)
30
5
set fou
r
m
a
in
p
illars in
m
a
n
a
g
i
ng
d
i
ab
etes,
n
a
m
e
l
y
: ed
u
catio
n
,
d
i
et, ph
armaco
lo
g
y
and
ex
ercise.
DM
ex
p
e
rts
have
i
n
vent
e
d
t
h
e e
x
erci
se
pr
o
cedu
r
es t
h
o
u
g
h
n
o
t
al
l
of t
h
e t
y
pes we
re
reco
m
m
e
nded
fo
r
p
e
opl
e
wi
t
h
di
a
b
et
es
si
nce DM
i
s
a chr
oni
c
di
sea
s
e wi
t
h
va
ri
o
u
s
pat
i
e
nt
s’ c
o
n
d
i
t
i
ons
fr
om
m
i
l
d
t
o
severe
. Th
ose pat
i
e
n
t
s wi
t
h
com
p
l
i
cat
i
ons need t
o
ad
ju
st
t
h
e i
n
t
e
nsi
t
y
. Sl
owe
r
r
h
y
t
h
m
s and m
ovem
e
nt
s have
be
en creat
e
d
k
n
o
w
n
as
diabetic foot e
x
ercise
[4].
Vari
ous cl
i
n
i
c
al
benefi
t
s
f
r
o
m
t
h
e exerci
se
for
DM
pat
i
e
nt
s ha
ve bee
n
rep
o
rt
e
d
as we
l
l
as t
hose of
lab
o
rato
ry, esp
ecially th
e ro
le of gro
w
t
h
facto
r
.
Ne
r
v
e
gr
o
w
t
h
fa
ct
o
r
i
s
cal
l
e
d ne
ur
ot
r
o
p
h
i
n
, i
n
cl
udi
n
g
neu
r
ot
ro
p
h
i
n
-3
(N
T-
3)
.
NT-
3
co
nt
ri
b
u
t
e
s i
n
t
h
e
pre
v
e
n
t
i
o
n
of
de
ge
nerat
i
ve ne
u
r
o
n
s.
N
T
-3
i
s
uni
que
am
ong
n
e
uro
t
roph
in
s
in
term
s o
f
n
u
m
b
e
r an
d
p
o
ten
tial to
sti
m
u
l
ate, referri
ng
to
its ab
ilit
y to
activ
ate
m
u
l
tip
le
tyrosine kina
se
ne
urotrophin
receptor (e
g, TrkC
and TrkB). All
ne
urotrophins
are
in m
u
scles, but the m
a
jority
of
af
fere
nt
m
u
scl
e
s (
75%
) e
x
press
e
s T
r
kC
and
i
s
re
sp
o
n
s
i
ve t
o
NT
-3
.
M
u
scl
e
co
nt
ra
ct
i
ons i
n
di
abe
t
i
c
fo
ot
g
y
m
n
astics wil
l
trig
g
e
r th
e tran
slo
cation
o
f
GLUT4
so
t
h
a
t
t
h
e t
r
ans
p
ort
of
gl
uc
ose
i
n
to cells increases
. This
can
be em
pl
oy
ed as e
n
e
r
gy
a
n
d
re
duct
i
on
o
f
hy
pe
rgl
y
cem
ia. F
oot
e
x
erci
s
e
al
so i
m
pro
v
e
bl
o
o
d
ci
rc
ul
at
i
o
n
[
5
]
-
[1
0]
.
Seve
ral
st
udi
es
have
bee
n
pe
r
f
o
r
m
e
d on t
h
e
exerci
se
wi
t
h
hi
g
h
an
d m
i
l
d
i
n
t
e
nsi
t
y
assoc
i
at
ed wi
t
h
neu
r
ot
ro
p
h
i
n
,
but
not
t
h
e
o
n
e
s
wi
t
h
m
i
l
d
st
ret
c
hi
ng e
x
e
r
cises lik
e foo
t
ex
ercise related
with
NT-3, add
e
d wit
h
t
h
e u
n
cl
ear
pat
t
erns
of
cha
n
g
e
s i
n
N
T
-
3
l
e
v
e
l
s
. If t
h
e
pat
t
e
rn ca
n
be e
xpl
ai
ned sci
e
nt
i
f
i
cal
l
y
, t
h
e
m
a
nagem
e
nt
of dia
b
etes m
e
l
litus with
diabetic fo
ot gym
n
astics is accountable
[11]-[22].
Accord
ing
l
y, th
is stud
y is d
e
sig
n
e
d
to
d
e
termin
e th
e p
a
ttern
of ch
ang
e
s in
seru
m
lev
e
ls
o
f
NT-3
in
t
h
e i
m
provem
e
nt
o
f
di
abet
i
c
n
e
ur
o
p
at
hy
, a
f
t
e
r
doi
ng
di
a
b
et
i
c
f
oot
e
x
erci
se
.
2.
R
E
SEARC
H M
ETHOD
Thi
s
st
u
d
y
i
s
a t
r
ue ex
pe
ri
m
e
nt
al
one w
i
t
h
ran
dom
i
zed p
r
e-t
e
st
p
o
s
t
-t
est
cont
r
o
l
gr
o
up
desi
g
n
m
e
t
hod.
A t
o
t
a
l
of
36 s
u
bj
e
c
t
s
m
eet
i
ng t
h
e i
n
cl
usi
o
n a
n
d excl
usi
o
n c
r
i
t
e
ri
a were i
n
cl
ude
d i
n
t
h
e t
r
e
a
tm
ent
gr
o
up
(
18 s
u
b
j
ect
s) o
r
t
h
e c
o
nt
r
o
l
o
n
e (
1
8 s
u
b
j
ect
s)
wi
t
h
a
g
e m
a
t
c
hed sy
st
em
at
i
c
rando
m
sam
p
l
i
ng m
e
t
h
o
d
.
M
easuri
ng va
ri
abl
e
s was pe
rf
orm
e
d bef
o
re a
nd aft
e
r t
h
e t
r
eatm
e
nt
of perf
orm
i
ng di
abet
i
c
foot
gy
m
n
ast
i
c
s for
4
weeks
wi
t
h
once
-
dai
l
y
dos
i
ng.
T
h
e c
ont
r
o
l
g
r
o
u
p
di
d
n
o
t
pe
rf
o
r
m
di
abet
i
c
f
oot
e
x
er
ci
se, b
u
t
t
h
ei
r
dai
l
y
p
h
y
sical activ
ity as u
s
u
a
l.
In
cl
u
s
ion
criteria fo
r th
is st
u
d
y
were: (1) patien
t
s with
d
i
ab
etic n
e
uro
p
a
t
h
y o
f
mild
,
m
oderat
e
, o
r
s
e
vere l
e
vel
b
o
t
h
m
e
n and
w
o
m
e
n, (
2
) a
g
e
d
40
-
64 y
ear
s ol
d,
(3
) n
o
t
s
u
f
f
e
ri
n
g
f
r
om
a d
i
sease
affect
i
n
g t
h
e
l
o
we
r ext
r
em
it
y
and i
n
t
e
rfe
ri
n
g
exe
r
ci
se
per
f
o
r
m
a
nce,
(4
)
not
po
sse
ssi
ng
i
m
pai
r
ed re
nal
fun
c
tion
b
y
exa
m
in
in
g
t
h
e lev
e
ls
o
f
uric aci
d
,
urea and
creatin
in
e,
(5)
no
t h
a
v
i
ng
m
e
n
t
al illn
ess, m
a
lig
n
a
n
c
y,
i
m
p
a
ired
co
gn
i
tio
n
and
co
mmu
n
i
cation
d
i
sord
ers,
(6)
willin
g
to
b
e
a
sam
p
le b
y
sign
ing in
fo
rm
ed
co
n
s
en
t.
In
ad
d
ition
,
ex
cl
usio
n criterion
was alco
ho
l con
s
u
m
p
tio
n.
Foo
t
ex
ercise
can
i
m
p
r
ov
e blo
o
d
circu
l
ation
wh
ich
will b
e
assessed
by an
an
k
l
e brach
ial in
d
e
x
(AB
I
), sy
st
ol
i
c
an
d
di
ast
o
l
i
c
bl
o
od p
r
es
sure sco
r
i
n
g.
Thi
s
bl
o
o
d
ci
rcul
at
i
o
n and ene
r
gy
t
r
ans
p
ort
i
m
p
r
ov
em
en
t will also
im
p
r
ov
e cell
functio
n
.
Th
is will b
e
a
b
i
om
o
l
ecu
lar assessm
en
t th
roug
h the
m
easurem
ent
of se
r
u
m
prot
e
i
n l
e
vel
s
p
o
t
e
n
t
i
a
l
for i
m
prov
i
ng
di
abet
i
c
ne
ur
o
p
at
hy
i
s
N
T
-3
. T
h
e pat
t
e
rns
o
f
ch
ang
e
s in
lev
e
ls of NT-3
will b
e
an
alyzed
. Clin
ically, i
m
p
r
o
v
e
d
d
i
ab
etic n
e
uro
p
a
t
h
y will b
e
assessed
t
h
r
o
u
g
h
t
h
e si
gns a
n
d sym
p
t
o
m
s
of di
abet
i
c
neu
r
o
p
at
hy s
cale (DNS) and diabetic ne
uropathy exam
ination
(D
NE)
.
The
o
t
her c
o
nt
r
o
l
l
e
d
va
ri
abl
e
s a
r
e
age
,
se
x,
H
b
A1c
,
B
M
I
,
D
M
an
d
hy
pe
rt
ensi
o
n
d
u
rat
i
o
n,
re
nal
fun
c
tion
an
d lip
id
profile.
Vari
a
b
l
e
s i
n
t
h
i
s
researc
h
i
n
cl
ude t
h
e i
n
de
pe
nde
nt
,
de
pen
d
e
n
t
an
d c
ont
rol
l
ed o
n
es
. T
h
e i
nde
pe
nde
nt
i
n
cl
ude
s di
ab
e
t
i
c
foot
exe
r
ci
se, t
h
e act
i
v
i
t
y
of pe
rf
or
m
i
ng
diabetic foot exercise
with the proce
d
ures as
speci
fi
ed
by
P
E
R
K
E
N
I,
w
h
i
l
e
t
h
e de
pen
d
e
n
t
ones a
r
e AB
I
score
s
, sy
st
ol
i
c
and
di
ast
o
l
i
c
b
l
oo
d p
r
ess
u
re
,
DN
S,
DNE
, ser
u
m
l
e
vel
s
o
f
N
T
-
3
. I
n
ad
di
t
i
on t
o
t
h
e co
nt
r
o
l
l
e
d,
nam
e
ly
t
h
e de
gree
of
di
abet
i
c
neu
r
opat
h
y
b
a
sed
o
n
ENMG ex
am
i
n
atio
n, d
i
ab
etic p
a
tien
t
s with statu
s
o
f
Hb
A1
c lev
e
ls, lipid
p
r
o
f
ile of to
tal ch
o
l
esterol lev
e
l,
HDL
, LD
L an
d t
r
i
g
l
y
ceri
d
e
,
renal
f
u
nct
i
on
of
uri
c
aci
d
,
u
r
ea, an
d cr
eat
i
n
i
n
e l
e
vel
s
, D
M
and
hy
pert
e
n
si
o
n
duration, BMI, age, and
sex.
Seru
m
lev
e
ls o
f
NT-3
were ex
am
in
ed
with
reag
en
ts of
Human
NT-3
Elisa k
it o
f
RayBio
tech
,
In
c.
p
r
od
u
c
ts,
N
o
r
c
r
o
ss, GA
3
0092
, U
S
A
,
Cat: ELH
-N
T-
3, Lo
t: 5
2
3
1
4
0
177
.
D
i
agn
o
sis o
f
diab
etic n
e
u
r
opath
y is
confirm
e
d with electroneuromyo
graphy (ENMG) e
x
am
ination.
The st
u
d
y
was
con
duct
e
d i
n
t
h
e cl
i
n
i
c
of i
n
t
e
rnal
m
e
di
ci
ne and ne
ur
ol
o
g
i
cal
of Gene
ral
Hos
p
i
t
a
l
at
PKU
Mu
h
a
m
m
ad
iyah
, Y
ogyak
a
r
t
a -
In
donesia. Th
e pr
o
t
oco
l
f
o
r
th
e r
e
sear
ch
h
a
s b
e
en
ap
pro
v
e
d
b
y
the eth
i
cs
committee
of the Faculty of Medicine, Gaj
a
h Mada
Unive
r
sity, and conducte
d in accorda
n
ce
with the
declaration of Helsinki. Data
analysis was perform
e
d
using S
PSS
21, the level of significance
was
set at p
<0.05.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
S
SN
:
2
252
-88
06
IJPHS Vol. 4, No. 4, D
ecem
ber 2015
:
304 – 309
30
6
3.
R
E
SU
LTS AN
D ANA
LY
SIS
Prelimin
ary d
a
ta fo
un
d, th
e su
bj
ects in
bo
th g
r
oup
s su
ffe
re
d fr
om
no si
gn
i
f
i
cant
di
ffe
ren
ces of m
i
l
d
,
m
oderat
e
an
d s
e
vere
ne
ur
o
p
at
hy
(
p
0.
3
7
0
)
i
s
sho
w
n i
n
Ta
bl
e 1.
Tabl
e
1. B
a
si
c
charact
e
r
i
s
t
i
c
-
Level
of
Ne
u
r
opat
h
y
di
a
b
et
i
c
Neur
opathy
Diabetic
E
x
er
cise Gr
oup
Contr
o
l Gr
oup
Total
p*
n
%
n
%
Mild
1
5.
6%
3
16.
7%
4
0.
370
M
oder
a
te
6
33.
3%
3
16.
7%
9
Severe
11
61.
1%
12
66.
7%
23
Total
18
100%
18
100%
36
* =
Fishe
r’s
exact test
There
was
no
si
gni
fi
ca
nt
di
f
f
e
rence i
n
t
h
e e
x
am
i
n
at
i
on of
renal
f
u
nct
i
on
i
n
t
h
e l
e
vel
s
o
f
uri
c
aci
d (
p
0.
61
9
)
an
d c
r
e
a
t
i
n
i
n
e (
p
0.
65
2)
. U
r
ea l
e
vel
s
sh
owe
d
a si
gn
i
f
i
cant
di
f
f
ere
n
ce (
p
0
.
00
6)
bu
t still it is wit
h
in
t
h
e
rang
e
o
f
norm
a
l li
mits (Tab
le
2
)
.
Tabl
e 2.
B
a
si
c C
h
aract
eri
s
t
i
c
–
R
e
nal
f
unct
i
on
Variable
E
x
er
cise Gr
oup
Contr
o
l
Gr
oup
p*
Mean
+
SD
Mean
+
SD
Ur
ic acid (
m
g/dl)
5.
405 +
1.
235
5.
277 +
1.
059
0.
619
Ur
eu
m
(
m
g/dl)
23.
388
+
6.
30
8
21.
988 +
5.
88
2
0.
006
Cr
eatinine (
m
g/dl)
0.
841 +
0.
140
0.
826 +
0.
167
0.
652
* =
Fishe
r’s
exact test
Age s
u
bjects
were m
a
tched
so that the
value of
p
=
1
.
Other cha
r
acteristics also showed unsi
gni
ficant
diffe
re
nce: ge
n
d
er
(
p
0.
44
3)
, m
a
ri
t
a
l
st
at
us
(
p
0.
33
8)
,
e
duc
at
i
on (
p
0.
3
0
9
)
, occ
u
pat
i
o
n
(
p
0
.
19
4)
, t
h
e typ
e
of
diabetes t
h
era
p
y (
p
0.
08
4
)
, B
M
I
(
p
0.
54
5)
. T
h
ere
was
a
si
gni
fi
ca
nt
di
ff
erent
i
n
DM
c
ont
rol
st
at
u
s
i
n
bot
h
gr
o
ups
,
Hb
A
1
c
l
e
vel
(
p
0
.
01
9) (
T
ab
le 3)
.
Table 3.
Basic characte
r
istic
-
categorical dat
a
Variable
E
x
er
cise Gr
oup
n=
Contr
o
l Gr
oup
n=
Total
n=
p*
Age : 40-
48 y
o
48-
56 y
o
56-
64 y
o
Total
2
7
9
2
7
9
4
14
18
1.
000
18
18
36
Sex : Mal
e
Fe
m
a
le
Total
3
15
6
12
9
27
0.
443
18
18
36
Marital
Status :
Unm
e
rried
Mar
r
ied
W
i
dow(
e
r)
Total
0
14
4
1
16
1
1
30
5
0.
338
18
18
36
Education : Ele
m
e
n
tary
High school
College
Total
3
9
6
1
6
11
4
15
17
0.
309
18
18
36
Occupation : entr
epr
e
neur
em
ploy
ee
ousewife/pensi
o
n
Total
2
8
8
7
6
5
9
14
13
0.
194
18
18
36
HbA1c : Good = < 6.
5%
Fair
ly = 6.
5-
7.
0%
Poor
ly
=
> 7.
0%
Total
6
1
11
0
1
17
6
2
28
0.
019
18
18
36
Therapy : O
r
al Ant
i
Diabetic
Oral
Anti Diabetic
+ Insulin
No therapy
Total
8
5
5
10
8
0
18
13
5
0.
084
18
18
36
Evaluation Warning : The document was created with Spire.PDF for Python.
I
J
PH
S I
S
SN
:
225
2-8
8
0
6
Ser
u
m
Level C
h
anges
of Neut
rophi
n
-3 After
Perfor
ming
Diabetic F
o
ot Ex
ercise in
.... (Tri Wahyuliati)
30
7
BM
I
: Nor
m
al = 18,
5-
22,
9
W
ith Risk=23,
0-
24,
9
Obese I
= 25,
0-
29,
9
Obese II
> 30
Total
6
3
8
1
10
1
5
2
16
4
13
3
0.
545
18
18
36
* =
Fishe
r’s
exact test
Th
e d
i
fferen
ce was sig
n
i
ficant in
u
r
ea and
Hb
A1
c le
v
e
ls for b
o
t
h
group
s.
It will b
e
an
alyzed
fu
rth
e
r
by classifying t
h
em
as co-vari
a
nt in t
h
e statis
tical analysis.
The othe
r vari
ables of basic
cha
r
acteristic
are ABI
(
p
0.05
6)
, systo
lic b
l
ood
p
r
essure (
p
0.
77
2)
,
d
i
asto
lic b
l
ood p
r
essur
e
(
p
0.
50
6
)
, D
N
S
(
p
0.
38
7
)
,
D
N
E (
p
0.761
)
,
serum lev
e
ls o
f
NT-
3
(
p
0.
6
7
6
)
, du
rat
i
o
n
o
f
d
i
ab
etes m
e
l
litu
s (
p
0.
26
6
)
,
du
rat
i
o
n o
f
hy
pert
e
n
si
o
n
(
p
0.68
0)
, cho
l
ester
o
l (
p
0.
73
5)
, HDL (
p
0.665
), LD
L
(
p
0.479
) and
t
r
ig
lycerid
e (
p
0
.
7
25)
, r
e
sp
ectiv
ely
(
T
ab
le
4).
Table
4. Basic
Characteristic - Ratio Data
Variabel
E
x
er
cise Gr
oup
n
= 18
Contr
o
l Gr
oup
n
= 18
p*
Mean
+
SD
Mean
+
SD
ABI 0.
919
+
0.
068
0.
886 +
0.
048
0.
056
Sy
stolic (
m
m
H
g)
132.
22
0 +
18.
568
131.
67
0 +
13.
827
0.
772
Diastolic (
m
m
H
g
)
81.
110 +
8.
32
4
80.
830 +
5.
49
1
0.
506
DNS 2.
110
+
1.
023
2.
170 +
0.
985
0.
387
DNE 3.
220
+
2.
211
4.
280 +
2.
697
0.
761
NT
-
3
(
pg/m
L
)
2.
850
+
0.
731
1.
199 +
0.
493
0.
676
Dur
a
tion of DM
(yr
s
)
7.
330 +
4.
777
8.
170 +
4.
962
0.
266
Dur
a
tion of hy
per
t
ension (
y
r
s
)
2.
500 +
0.
371
3.
610 +
0.
722
0.
680
Cholesterol
(m
g/dl)
198.
22
2 +
39.
478
206.
77
7 +
58.
567
0.
735
HDL
(m
g/dl)
51.
972
+
10.
6
9
2
46.
677 +
13.
6
2
1
0.
665
L
D
L (
m
g/dl)
142.
44
4 +
29.
876
137.
33
3 +
52.
926
0.
479
Triglyceride
(
m
g/d
l
)
143.
11
1 +
77.
398
153.
38
8 +
47.
241
0.
725
* =
Fishe
r’s
exact test
At the end
of
the study, the
an
alysis was c
o
nducted
on
15 s
u
bject
s in e
x
ercise
group, because
3
su
bj
ects (16
.
6%) dropp
ed
o
u
t, as o
n
e
subj
ect ex
p
e
rien
ced
an
o
s
teo
a
rthritis g
e
nu
and
two
o
t
h
e
r subj
ect
s with
myalgia (Table
5).
Tab
l
e
5
.
C
o
m
p
ar
atio
n r
e
su
lt betw
een
t
w
o gro
up
Variable
Exercise Group
n
= 15
Contr
o
l Gr
oup
n
= 17
p***
(C)
Begin
E
nd
p**
(A)
Begin
E
nd
p**
(B)
Mean
+
SD
Mean
+
SD
Mean
+
SD
Mean
+
SD
ABI 0.
92
+
0.
06
1.
01 +
0.
08
0.
002
0.
88 +
0.
04
0.
88 +
0.
05
0.
131
0.
01
Sy
stolic 132.
00
+
20.
3
3
124.
00 +
14.
0
4
0.
014
131.
76 +
14.
2
4
132.
35 +
11.
4
7
0.
668
0.
01
Diastolic 82.
00
+
8.
61
78.
67 +
9.
90
0.
055
80.
88 +
5.
65
82.
06 +
5.
32
0.
216
0.
01
DNS 2.
13
+
1.
06
1.
07 +
0.
96
0.
001
2.
18 +
1.
01
2.
18 +
1.
01
1.
000
0.
01
DNE 3.
20
+
2.
14
1.
73 +
1.
66
0.
001
4.
41 +
2.
71
4.
53 +
3.
01
0.
543
0.
01
NT
-
3
1.
05
+
0.
23
1.
26 +
0.
38
0.
049
1.
19 +
0.
50
1.
98 +
1.
81
0.
264
0.
01
*
*
= Paired
t test
**
*
= Ge
neral
l
i
n
e
a
r m
odel
Th
e
stud
y foun
d a si
gn
if
ican
t in
cr
ease i
n
the e
x
ercise
group,
ABI
s
c
or
e
s
w
e
r
e
co
mp
a
r
ed
to
th
e
cont
rol
gr
o
u
p
,
fr
om
(0.
9
2
+
0.
06
) i
n
t
o
(
1
.
0
1 +
0.
08
)
p
0.
00
2 vs
.
(0
.8
8
+
0.
0
4
) i
n
to
(0
.8
8 +
0.
05
)
p
0.
13
1,
respectively.
T
h
is m
eans there were
sign
if
ican
t d
i
f
f
e
r
e
n
ces f
oun
d in
t
h
e t
w
o gr
oup
s
w
ith
th
e v
a
l
u
e
o
f
p
0.
01
.
It occ
u
rred i
n
response to
m
u
scle contra
ction of
e
n
dot
h
elium
-
depe
ndent vas
o
dilatation
or acetylcholine
.
M
u
scl
e
cont
ra
ct
i
on i
n
f
oot
gy
m
n
ast
i
c
s t
r
igge
re
d ne
ur
ot
r
a
nsm
i
tt
er of a
cet
y
l
chol
i
n
e t
o
get
h
e
r
wi
t
h
t
h
e M
3
m
u
scarinic receptor that also trigge
red e
n
dothelial derive
d vas
o
dilator
pr
ostanoid, and then
diffuse
d
into
m
u
scles causing
vas
o
relaxati
on a
n
d a
decreas
e
i
n
peri
phe
ral
resi
st
ance [1
2]
,
[
1
3
]
,
[
1
8]
.
Sy
st
ol
i
c
bl
o
o
d
pres
su
re i
n
e
x
erci
se
gr
o
u
p
decrea
sed si
gni
fi
cant
l
y
, fr
om
(13
2
.
00 +
20
.3
3
)
i
n
t
o
(1
2
4
.
00
+ 1
4
.
0
4) p 0.
01
4 vs (
1
3
1
.
7
6
+ 14
.2
4
)
i
n
t
o
(
1
3
2
.35
+ 1
1
.47)
p 0.66
8, r
e
sp
ec
tiv
el
y. Th
erefo
r
e, th
e two
gr
o
ups
ha
d si
g
n
i
f
i
cant
di
f
f
ere
n
ces wi
t
h
p va
l
u
e
o
f
0.
01
.
D
i
asto
lic b
l
ood
pr
essur
e
also
d
e
cr
eased thou
gh no
t
si
gni
fi
ca
nt
i
n
exerci
se
gr
o
u
p
at
(82
.
0
0
+
8.
61
) i
n
t
o
(
7
8
.
6
7
+ 9
.
9
0
)
p
0.
05
5,
w
h
ereas t
h
e co
nt
r
o
l
g
r
o
up
wa
s
Evaluation Warning : The document was created with Spire.PDF for Python.
I
S
SN
:
2
252
-88
06
IJPHS Vol. 4, No. 4, D
ecem
ber 2015
:
304 – 309
30
8
obs
er
ved
wi
t
h
no si
gni
fi
cant
i
n
crease
fr
om
(8
0.
8
8
+ 5.
6
5
)
i
n
t
o
(
8
2
.
0
6
+
5.
32
) p
0.
2
1
6
.
R
e
sul
t
s
i
n
ea
ch o
f
th
ese
g
r
ou
p
s
were
n
o
t
sign
ifican
t, yet th
ey
were si
g
n
i
fica
nt (p
0.01) whe
n
com
p
ar
ed
bet
w
een
t
h
e
t
w
o
gr
o
u
p
s
d
u
e
to
th
e p-v
a
lu
e o
f
0.055
for th
e ex
ercise
group. Hence
,
this was closer
to the significance if the degree of
si
gni
fi
ca
nce w
a
s
p
<
0
.
0
5, w
h
i
l
e
i
n
t
h
e
c
ont
r
o
l
g
r
o
u
p
, p
-
val
u
e was fart
he
r of p 0.
2
1
6
.
Im
pr
o
v
em
ent
s
i
n
bl
o
o
d
press
u
re occ
u
r
r
ed
wi
t
h
rega
r
d
t
o
t
h
e o
n
set
of
vas
o
rel
a
xat
i
on a
n
d a
decre
a
se i
n
pe
ri
pheral resistance.
Ove
r
all,
t
h
i
s
af
fect
ed
bl
oo
d ci
rcul
at
i
o
n
an
d
pres
su
re i
m
provem
e
nt
s [
12]
,
[
1
3
]
,
[
1
8]
.
For
DNS sc
ores, the res
u
lts revealed a si
gni
ficant
i
m
provem
e
nt
i
n
ex
erci
se gr
o
u
p
,
f
r
om
(2.
13 +
1.
06
) i
n
t
o
(
1
.
0
7 + 0.9
6
)
p 0
.
0
1
an
d i
n
t
h
e
cont
r
o
l
gr
o
u
p
from
(2.1
8 +
1.0
1
) i
n
t
o
(2
.
18 + 1.
0
1
)
p 1.
00
,
r
e
sp
ectiv
ely.
Bo
th
gro
u
p
s
sh
ow
ed
si
gn
ifican
t d
i
fferen
t resu
lts with
p
0.
01
. A si
g
n
i
f
i
cant
im
pro
v
e
m
ent
of
D
N
E
v
a
lu
es also
o
c
cur
r
e
d
in
th
e ex
ercise g
r
o
u
p
w
ith
a d
e
clin
e, f
r
o
m
(
3
.20
+ 2
.
14
)
i
n
to
(1
.7
3
+
1
.
6
6
)
p
0
.
001,
i
n
t
h
e c
o
nt
rol
gr
o
up
fr
om
(4
.4
1 +
2.
7
1
) i
n
t
o
(
4
.
5
3
+
3.
0
1
)
p
0.
5
4
3
,
c
o
nsec
ut
i
v
el
y
.
B
o
t
h
gr
o
u
p
s
re
v
eal
ed
si
gni
fi
ca
nt
di
f
f
e
rent
res
u
l
t
s
w
i
t
h
p 0.
01
. Suc
h
im
pro
v
em
ent
s
were d
u
e t
o
m
u
scl
e
cont
ract
i
on i
n
di
a
b
et
i
c
fo
ot
gym
n
astics ca
using inc
r
ease
d
calcium
ions, then a
c
tivat
ed
the ade
n
ylate cyclase enzym
e
,
he
nce, t
h
e AT
P wa
s
change
d into
cAMP. Furt
he
rm
ore, cAMP helpe
d
th
e m
e
tab
o
lism
p
r
o
cess an
d
ab
sorp
tio
n
of ex
tracellu
lar
gl
uc
ose
by
i
n
t
r
a GL
UT
4
v
e
si
cl
es t
r
ansl
o
cat
i
on t
o
m
o
ve n
e
ar th
e me
m
b
ran
e
surface to
tran
sp
ort th
e
extracellular
gl
ucose to t
h
e ce
ll to be
used as
energy
a
nd t
o
reduce
hype
rgl
y
ce
m
i
a. Increa
sed c
A
MP activated
cAM
P
res
p
ons
e el
em
ent
-
bi
n
d
i
ng
pr
ot
ei
n (C
R
E
B
)
assi
st
i
n
g
m
e
rgi
ng
dam
a
ged
fra
gm
ent
s
of a
x
o
n
s a
nd
m
y
eli
n
of di
a
b
et
i
c
neu
r
o
p
at
hy
. Im
pr
o
v
ed
bl
o
od ci
rc
ul
at
i
on i
m
prov
ed t
h
e su
p
p
l
y
of m
a
t
e
ri
al
s needed
fo
r re
gen
e
rat
i
n
g
and
repai
r
i
n
g a
x
o
n
s a
nd m
y
el
in. S
u
c
h
m
echani
s
m
woul
d
re
pai
r
pe
rce
p
t
i
b
l
e
cel
l
funct
i
o
n
wi
t
h
i
m
provem
e
nt
of
D
N
S an
d DN
E [2
3
]-[
25
].
Th
e
NT-3 level was ex
am
in
ed
an
d d
i
scovered a sign
ifican
t im
p
r
o
v
e
m
e
n
t
at its lev
e
l
,
n
a
m
e
ly, in
exerci
se
gr
o
u
p
fr
om
(1.0
5 +
0.
23
) i
n
t
o
(
1
.
2
6
+ 0.
3
8
)
p
0.
04
9,
w
h
ereas i
n
t
h
e c
ont
r
o
l
gr
o
u
p
f
r
o
m
(1.1
9 +
0.
5
0
)
i
n
t
o
(
1
.
98 + 1
.
81
) p
02
6
4
, res
p
ect
i
v
el
y
.
Di
f
f
e
rences
were s
i
gni
fi
ca
nt
wi
t
h
a p-val
u
e o
f
0.
01
. These
resul
t
s are
in
accorda
n
ce with pre
v
ious data,
clai
ming
that the m
a
jori
ty (75%)
of affe
rent m
u
scle expresses
TrkC
and is
resp
o
n
si
ve t
o
NT -
3
.
F
oot
exerci
se a
r
e m
o
re a l
o
cal
w
o
rk i
n
pe
ri
p
h
e
r
a
l
t
h
ro
u
gh m
a
ni
pul
at
i
n
g l
o
wer
l
i
m
b
m
u
scles, th
u
s
, m
o
re lo
cal i
m
p
act g
e
n
e
rates.
Neuro
t
roph
in
lev
e
ls rep
a
i
r
th
ro
ugh
foo
t
ex
ercise, relyin
g
on
lo
cal
facto
r
s, can
b
e
m
a
d
e
po
ssib
l
e b
y
th
e
m
ech
an
ism
o
f
th
e av
ailab
l
e literatu
re. Th
e
d
a
ta sho
w
, th
at th
e g
l
u
c
ose
tran
sp
orter (GLUT), esp
ecially GLUT-4 i
s
th
e m
a
j
o
r i
n
sul
i
n
-res
p
on
s
i
ve gl
uc
ose
t
r
ans
p
ort
e
r
,
l
o
cat
ed
especially in cell
m
u
scle and adipose.
In
the ab
sen
ce of i
n
su
li
n
,
ab
ou
t 90
p
e
rcen
t GLUT-4
is in
t
r
acellu
larly
lo
cated
. Con
t
ractio
n
o
f
m
u
scles in
the foot exercise ca
n stim
ulate G
L
UT-4
tran
slocatio
n
to
th
e p
l
asm
a
m
e
m
b
rane an
d
enha
nce
gl
uc
o
s
e t
r
ans
p
o
r
t
i
n
skel
et
al
m
u
scl
e
t
h
ro
u
gh
di
f
f
e
r
ent
pat
h
w
a
y
s
fr
om
i
n
sul
i
n
(i
nsul
i
n
in
d
e
p
e
nd
en
t). It
allo
ws a
p
e
rson
with
d
i
abetes
to
en
ter
m
u
scles with
en
erg
y
b
y
l
o
cal sti
m
u
l
atio
n
i.e. leg
m
u
scl
e
cont
ra
ct
i
on i
n
fo
ot
exerci
se.
I
n
o
r
der
t
o
b
u
i
l
d
n
e
ur
ot
r
o
p
h
i
n
pr
ot
ei
ns
i
n
rege
nerat
i
v
e
f
u
nct
i
o
n
t
h
e
ener
gy
a
v
ai
l
a
bl
e i
s
em
pl
oy
ed [
23]
-
[
29]
.
4.
CO
NCL
USI
O
N
Th
us, i
t
ca
n
b
e
co
ncl
u
ded
t
h
at
i
n
pat
i
e
nt
s
wi
t
h
di
abet
i
c
ne
ur
op
at
hy
,
d
i
abet
i
c
fo
ot
e
x
erci
se ha
s a
p
e
r
i
p
h
e
r
a
l ef
f
e
ct o
n
a clin
ically sig
n
i
f
i
can
t i
m
p
r
ov
em
en
t
b
a
sed
on
A
B
I
sco
r
es, systo
lic an
d
d
i
ast
o
lic b
l
ood
p
r
essure,
DNS
an
d DNE.
A si
g
n
i
fican
t in
crease in
seru
m
le
v
e
ls
o
f
NT-3.
Accord
ing
l
y, th
e stud
y sug
g
e
sts (1) clin
ician
s
to
include a
p
propriate physi
cal
exercise suitable for
th
e p
a
tien
t
s’ co
nd
itio
n. Low i
m
p
act wo
rk
out su
ch
as d
i
ab
e
tic fo
o
t
ex
ercise can
still
b
e
ap
p
lied, esp
ecially
in
p
a
tien
t
s with
sev
e
re con
d
ition
s
.
(2)
n
u
rses,
g
y
m
n
astics g
r
ou
p
s
,
h
ealth
coun
selors, and
v
a
riou
s stak
eho
l
ders in
h
ealth
care syste
m
s to
always m
a
n
a
g
e
to
imp
l
em
en
t p
h
y
sical exercise
including
dia
b
et
i
c
f
oot
gy
m
n
asti
cs i
n
any
ef
fo
rt
t
o
i
m
prove
heal
t
h
st
at
us. (
3
)
pat
i
e
nt
s an
d s
o
ci
eties to
p
e
rform
a
c
tiv
ely ev
en
t
h
e low im
pact exercis
e
l
i
k
e di
abet
i
c
f
o
ot
gy
m
n
ast
i
c
s
as pr
o
v
en t
o
p
r
o
v
i
d
e
ben
e
fi
t
s
. (4
) f
u
rt
her
re
search t
o
be
d
one
wi
t
h
vari
e
d
d
o
se
and
d
u
rat
i
o
n f
o
r t
h
e o
b
ser
v
at
i
on, s
u
bj
ect
s sel
ect
i
on wi
t
h
h
o
m
ogene
ou
s H
b
A
1
c,
o
b
ser
v
at
i
on
on c
o
nst
r
ai
ns o
r
tr
ig
g
e
r
i
ng
ad
her
e
n
ce
f
actor
s to
wor
kou
t reg
u
l
ar
ly, (5
)
t
h
erap
eu
tic strateg
i
es in
th
e fu
t
u
re t
o
con
s
id
er
neu
r
ot
ro
p
h
i
c
f
act
ors
part
i
c
ul
arl
y
NT-
3
l
e
ve
l
gi
ven as t
h
e l
east affected
by diabetic
foot exercise,
for instance,
an i
n
t
r
a-m
u
scu
l
ar i
n
ject
i
o
n
f
o
r sy
nt
het
i
c
NT
-
3
or
an
oi
nt
m
e
nt
.
Thi
s
st
u
d
y
fi
n
d
i
n
gs has se
ve
ral
l
i
m
i
t
a
t
i
ons:
(1)
n
o
assess
m
e
nt
on ne
ur
o
t
ro
phi
n l
e
vel
s
of s
k
el
et
al
m
u
scl
e
s
i
n
t
h
e feet
, (2
) n
o
bi
o
p
sy
as a defi
ni
t
i
v
e di
agn
o
si
s
of t
h
e o
n
set
o
f
dege
nerat
i
o
n and re
ge
nerat
i
on
, (3
)
t
h
e
s
u
b
j
ect
s o
f
t
h
e st
udy
hav
e
i
n
equi
val
e
nt
Hb
A
1
c l
e
vel
s
bet
w
ee
n t
w
o g
r
o
u
p
s, (
4
) su
b
j
ect
s of t
h
i
s
researc
h
were
n
o
t
gr
ou
p
e
d acc
or
di
n
g
t
o
t
h
e
ba
si
c st
at
us
of
sev
e
ri
t
y
i
n
di
abet
i
c
neu
r
opat
h
y
.
REFERE
NC
ES
[1]
Anonim, “Indonesian d
a
ta and
in
form
ation center
s”, 2011
. pdp
ersi.co.id.
[2]
Anonim, “the Basic Health
Research –
Indone
sian
republic health
department”, 20
07.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
J
PH
S I
S
SN
:
225
2-8
8
0
6
Ser
u
m
Level C
h
anges
of Neut
rophi
n
-3 After
Perfor
ming
Diabetic F
o
ot Ex
ercise in
.... (Tri Wahyuliati)
30
9
[3]
Anonim, “Limb Loss Task Force/Amputee Coalition,
Ro
admap for Preventing Limb Loss in America:
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m
e
ndatio
ns From
the 201
2 Lim
b
Loss
Tas
k
Force”, Knoxv
ille
, Tenn
essee, 2012.
[4]
Perkumpulan Endokrinologi In
donesia (P
ERKENI), “Konsensus Pengelolaan
Da
n Pencegah
an Diabetes Melitus
Tipe 2 Di Indon
esia”, 2011
.
[5]
Anonim, “Neurotrophins”, En
cy
clopedia of
the N
e
urol
ogical Sciences Elsevier
Science (USA), 20
03.
[6]
Anonim, “Neurotrophins”, Th
e F
r
ee
En
cy
cloped
i
a From Wikiped
i
a, 2012.
[7]
Blesch A., “Neu
rotrophic factor
in neurodeg
e
ner
a
tion”,
Brain
Pa
thol
., vol. 16
, pp
.
295-303, 2006
.
[8]
Blesch A., Tu
szy
n
ski MH.,
“Neu
rotrophic
Factor
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y: NGF, BDNF and NT-3
”,
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clopedia
o
f
Neuroscience, p
p
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[9]
Anand P., Ter
e
n
ghi G., Warner
G., K
opelman P., Williams-Chest
nut RE., Sinicro
p
i DV.,
“The ro
le of
endogenous
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ath
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”,
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ture M
e
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