Higher Levels Of Chronic Stress Research Articles

ReCAP: Would Women With Breast Cancer Prefer to Receive an Antidepressant for Anxiety or Depression From Their Oncologist?

Patient treatment preferences for the management of anxiety and depression influence adherence to treatment and treatment outcomes, yet the preferences of patients with breast cancer for provider-specific pharmacologic management of anxiety and depression is unknown. This study examined the antidepressant prescriber preferences of patients with breast cancer and their preferences for treatment by a mental health professional. Patients with breast cancer (stages 0 to IV) were asked two questions: “Would you be willing to have your oncologist treat your depression or anxiety with an antidepressant medication if you were to become depressed or anxious at any point during your treatment?” and “Would you prefer to be treated by a psychiatrist or mental health professional for problems with either anxiety or depression?” In addition, the Distress Thermometer and Problem List, Hospital Anxiety and Depression Scale, Risky Families Questionnaire, and demographic information were assessed. One hundred twenty-five participants completed the study. A total of 60.4% were willing to accept an antidepressant from an oncologist, and 26.3% preferred treatment by a mental health professional. The 77.3% who were willing to receive an antidepressant from their oncologist reported either no preference or that treatment by a mental health professional did not matter (P = .01). Participants taking antidepressants (P = .02) or reporting high chronic stress (P = .03) preferred a mental health professional. The majority of patients accepted antidepressant prescribing by their oncologist; only a minority preferred treatment by a mental health professional. These findings suggest that promoting education of oncologists to assess psychological symptoms and manage anxiety and depression as a routine part of an outpatient visit is beneficial

Effectiveness of different corticosterone administration methods to elevate corticosterone serum levels, induce depressive-like behavior, and affect neurogenesis levels in female rats

High levels of chronic stress or stress hormones are associated with depressive-like behavior in animal models. However, slight elevations in corticosterone (CORT) – the major stress hormone in rodents – have also been associated with improved performances, albeit in a sex-dependent manner. Some of the discrepancies in the literature regarding the effects of high CORT levels may be due to different administrations methods. The current study aims to compare the effects of ∼40mg/kg given either via subcutaneous injection, through an implanted pellet, or in the drinking water, for ∼21days on CORT serum levels, depressive-like behavior in the forced swim test (FST), and neurogenesis levels in the dentate gyrus (DG) in adult female rats. We found that animals exposed to the daily injections showed elevated CORT levels throughout the administration period, while the pellet animals showed only a transient increase, and drinking water animals revealed no elevation in CORT in serum. In addition, only the injection group exhibited higher levels of immobility in the FST. Interestingly, animals receiving CORT via injection or drinking water had lower numbers of doublecortin-positive cells in the ventral DG one week after the last CORT administration compared to animals implanted with a CORT pellet. These results will contribute to the growing literature on the effects of chronic CORT exposure and may help to clarify some of the discrepancies among previous studies, particularly in females.

Baseline Religion Involvement Predicts Subsequent Salivary Cortisol Levels Among Male But not Female Black Youth.

Background:Compared to Whites, Blacks are exposed to higher levels of chronic stress in the United States. As a result, major Black-White differences exist in the baseline and response of cortisol. Yet, the potential association between baseline religiosity and subsequent cortisol levels of Blacks are not known.Objectives:In the current study we aimed to determine the association between baseline religious behaviors and daytime salivary cortisol level among male and female Black youth.Materials and Methods:With a longitudinal design, data came from wave 1 (1994) and wave 6 (2000) of a cohort from an urban area in the Midwest of the United States. The study followed 227 Black adolescents (109 males and 118 females) for six years. Socio-demographics and religious behaviors (frequency of participation in religious activities) were measured at baseline. Base morning cortisol level at wave 6 was the outcome. We fitted a linear regression model to test the association between baseline religiosity at wave 1 and cortisol level at wave 6, while baseline age, socio-economics, and psychological symptoms were controlled.Results:In the pooled sample, frequency of participation in religious activities at baseline was negatively associated with mean cortisol level at follow up (r = -0.29, P > 0.01) among all, males (r = -0.38, P > 0.01), but not females (r = -.20, P > 0.05). Frequency of participation in religious activities remained a significant predictor of subsequent cortisol level (b = -0.283, 95% CI = -.107 - -0.022) while the effect of age, socioeconomics, and psychological symptoms were controlled. We could only find such an association among male Black youth (b = -0.368, 95% CI = -0.148 - -0.024) but not female Black youth (b = -0.229, 95% CI = -.113 - 0.011).Conclusions:Religiosity has been used as a coping mechanism among Blacks. Religiosity may also be related to stress regulation among Black youth. Future studies need to test complex associations between race, sex, religiosity, chronic stress, coping, and function of hypothalamo-pituitary-adrenal (HPA). It is not known whether male Black youth who are and those who are not religious differently cope with stress associated with daily discrimination and living in disadvantaged neighborhoods.

Regional cerebral glucose metabolism in the insula during acute stress predicts increased post-stress pulmonary inflammation in asthma

Although psychological factors contribute to the frequency, severity, and burden of asthma symptoms, the role of the brain in the pathophysiology and treatment of this disease is largely unknown. To examine the neural mechanisms which may regulate airway inflammation in asthma, we used [18F]fluoro-deoxyglucose positron emission tomography (FDG-PET) to identify neural circuits that are active during performance of a social stress task or a matched control condition. Asthmatic subjects with either high or low levels of chronic life stress underwent both stress and control conditions. Fractional exhaled nitric oxide (FeNO) was collected at baseline, as well as hourly post-challenge, and provided a measure of airway inflammation. These data reveal that, in those with high levels of chronic stress, an acute stressor leads to elevated post-stress FeNO levels relative to those with low chronic stress. In addition, increased regional glucose metabolism in the insular cortex predicts overall FeNO levels. This region of the insula is nearly identical to a region we identified in a previous study where activation following challenge with inhaled allergen predicted the increase in percentage of eosinophils in lung tissue 24 h later. These data corroborate previous evidence indicating a role for the insula in the interaction of emotion and inflammation in asthma and may lead to novel targets for future treatment.

A multi-method exploratory study of stress, coping, and substance use among high school youth in private schools.

There is growing awareness that students’ experiences of stress may impede academic success, compromise mental health, and promote substance use. We examined these factors in an under-studied population, private/independent high school students, using a multi-method (qualitative and quantitative), iterative data collection and analytic process. We first conducted qualitative interviews with faculty and staff at a number of highly competitive private schools, followed by an anonymous quantitative survey with 128 11th grade students from two of these settings. We then conducted a qualitative exploration of the quantitative results with a subset of students. Next, a set of Expert Panel members participated in qualitative interviews to reflect on and interpret study findings. Overall, we found students experienced high levels of chronic stress, particularly in relation to academic performance and the college admissions process. While students described a range of effective, adaptive coping strategies, they also commonly internalized these serious pressures and turned to alcohol and drugs to cope with chronic stress, although not typically at problematic levels. We discuss study implications for both schools and families derived from the Expert Panel.

Understanding Internet Use Among Dementia Caregivers: Results of Secondary Data Analysis Using the US Caregiver Survey Data.

BackgroundInformal caregivers of persons with dementia experience higher levels of chronic stress in the caregiving trajectory. The Internet provides diverse types of caregiver resources that may help ameliorate their stress and relevant negative outcomes. However, there is limited information about the prevalence and factors of using Internet-based resources for health- and caregiving-related purposes in informal caregivers of persons with dementia.ObjectiveSpecific aims of this study were (1) to determine the prevalence and factors of caregiver’s health-related Internet use and (2) to compare sociodemographic and caregiving-related characteristics between health-related Internet users and non–health-related Internet users among informal caregivers of persons with dementia.MethodsThis quantitative investigation was a descriptive correlational design using a secondary data analysis. Primary data were collected via a survey conducted in 2009 by the National Alliance for Caregiving and the American Association of Retired Persons. Telephone interviews utilizing standardized questionnaires were used to collect self-reported information about sociodemographics and caregiving-related history (N=450). Descriptive statistics and a hierarchical binary logistic regression analysis were completed based on the stress process model.ResultsApproximately 59% (265/450) of dementia caregivers were identified as health-related Internet users. Caregivers’ sociodemographics and their subjective responses of caregiving stress were the most significant factors to identify health-related Internet users followed by workload assisting in instrumental activities of daily living of persons with dementia. There were significant differences for caregiver’s age, levels of education and income, hours spent caregiving, and the relationship to persons with dementia between health-related Internet users and non–health-related Internet users (P<.05 for all). After controlling for confounding effects, younger age of persons with dementia (OR 0.278, 95% CI 0.085-0.906), higher education levels of caregivers (OR 3.348, 95% CI 2.019-5.552), shorter caregiving time spent per week (OR 0.452, 95% CI 0.243-0.840), higher levels of caregiver’s emotional stress (OR 1.249, 95% CI 1.004-1.555), and financial hardship (OR 4.61, 95% CI 1.416-14.978) were identified as newly emerging factors of health-related Internet use.ConclusionsAlthough the Internet provided useful resources for caregivers of persons with dementia, dementia caregivers reported lower levels of health-related Internet use compared to the general public. Our findings confirmed the impact of age, education levels, and/or income on Internet use reported in previous studies. However, the predictive value of subjective responses of caregiving stress for health-related Internet use was a new addition. These findings will assist health care providers, researchers, and policy makers in identifying who is the least likely to access Internet-based resources and how Internet-based strategies can best be designed, implemented, and distributed to meet the needs of this group of users.

Chronic Stress and Its Association with Psychological, Behavioral and Physiological Variables of Mexican College Students

Chronic Stress in an academic environment is considered to be the physiological, emotional, cognitive and behavioral reaction to scholastic events. The objective of this study was to identify chronic stress and its association with psychological, behavioral and physiological variables of Mexican students at a public university. A representative random sample of 527 students in 2012 was assessed. The Stress Symptoms Inventory and the Rossi classification were used and a multiple regression analysis was carried out. Results showed that 35.3% of students displayed high levels of chronic stress; 44.8% medium levels and 19.9% low levels, and the variables of working, digestion problems, nail-biting, feeling depressed, isolation from others, are predictors of chronic stress. Early detection of the variables associated with chronic stress in students would facilitate the implementation of educational programs aimed at developing students’ ability to cope with stressful situations.

An Explorative Study on Major Stressors and Its Connection to Depression and Chronic Stress among German Elite Athletes

Although research shows that chronic stress and specific stressful events (e.g. injury, failure) are associated with depressive symptoms in athletes, connections between chronic, major stressors and depressive symptoms are yet unknown. Therefore, the goal of the study was to gain new findings between major stressors and their relations to depressive symptoms and chronic stress. A total of 134 elite athletes provided data in an online survey. In addition to quantitative measurements (current depressive symptoms, and level of chronic stress), possible stressors were assessed qualitatively with an open ended question. By using content analysis to explore stressors, three different types of stressors were categorized: Double burden, sport specific demands, and conditions. Further statistical analysis found these stressors to be associated with dropout intentions, depression and chronic stress. Athletes, who reported sport specific demands (such as high training loads) as major stressors indicated higher levels of chronic stress and depressive symptoms than athletes without major stressors. Further research investigating sources of stress and its association to depressive syndromes in athletes could benefit from considering sport specific factors.

Severe occupational hand eczema, job stress and cumulative sickness absence.

Stress is known to activate or exacerbate dermatoses, but the relationships between chronic stress, job-related stress and sickness absence among occupational hand eczema (OHE) patients are inadequately understood. To see whether chronic stress or burnout symptoms were associated with cumulative sickness absence in patients with OHE and to determine which factors predicted sickness absence in a model including measures of job-related and chronic stress. We investigated correlations of these factors in employed adult inpatients with a history of sickness absence due to OHE in a retrospective cross-sectional explorative study, which assessed chronic stress (Trier Inventory for the Assessment of Chronic Stress), burnout (Shirom Melamed Burnout Measure), clinical symptom severity (Osnabrück Hand Eczema Severity Index), perceived symptom severity, demographic characteristics and cumulative days of sickness absence. The study group consisted of 122 patients. OHE symptoms were not more severe among patients experiencing greater stress and burnout. Women reported higher levels of chronic stress on some measures. Cumulative days of sickness absence correlated with individual dimensions of job-related stress and, in multiple regression analysis, with an overall measure of chronic stress. Chronic stress is an additional factor predicting cumulative sickness absence among severely affected OHE patients. Other relevant factors for this study sample included the 'cognitive weariness' subscale of the Shirom Melamed Burnout Measure and the physical component summary score of the SF-36, a measure of health-related life quality. Prevention and rehabilitation should take job stress into consideration in multidisciplinary treatment strategies for severely affected OHE patients.

Perfil de estrés y estrés crónico en migrantes mexicanos en Canadá

Establishing an association between high chronic stress levels and variables considered to be negative regarding the stress profile for Mexican migrants living in Edmonton, Canada. A simple random technique was used for choosing the target population; the sample size involved 58 migrants. The Nowack Stress Profile and Maslach Burnout Inventory were used to identify immigrants' stress symptoms during 2010-2011. Chronic stress levels were classified as being 24 % high, 45 % medium and 21 % low. Statistical regression analysis determined that a stressful situation and threat minimisation were predictors for developing high levels of chronic stress. Stress situation and threat minimisation were predictors for developing high levels of chronic stress; migrant women (unlike males) tended not to use threat minimisation to deal with stress.

Stress Management in Children

At present, school-age children suffer high levels of chronic stress that could produce potentially long-lasting effects. The aim of this pilot study was to evaluate the effects of mind-body integration practices and cooperative activities on stress levels and social interaction in 7- to 9-year-old children. We performed an intervention program once a week during 2 months in which children performed mind-body integration practices and cooperative activities. Our findings showed that these practices reduced cortisol levels and increased social connectedness. Moreover, we found that most of the children used the learned mind-body integration practices in stressful situations in their homes, even 5 months after the intervention. Our results demonstrated the positive impact of these helpful tools and the great plasticity of children's behavior, which enabled them to incorporate healthy habits. Overall, the intervention enhanced health at an individual level and favored social network diversity at a group level. Our research illustrates how children can incorporate techniques that help them cope with stressful moments and reveals the effectiveness of this experience in reducing cortisol levels. This study contributes to the understanding of how mind-body integration practices and social connectedness can be helpful in reducing chronic stress, a topic that, to the best of our knowledge, has been little studied in children.

Associations between intimate partner violence and posttraumatic stress symptom severity in a multiethnic sample of men with histories of childhood sexual abuse.

Little research exists identifying risk factors for posttraumatic stress symptoms (PTSS) among men with histories of childhood sexual abuse (CSA) who have been exposed to intimate partner violence (IPV). One hundred and fifty African American, Latino and non-Latino White men with histories of CSA participated in this study. An ordinary least squares regression model with race/ethnicity, HIV serostatus, and CSA severity treated as cofounders and with IPV as the predictor was fitted to predict level of PTSS. Higher levels of IPV were significantly associated with higher PTSS, as were higher levels of chronic stress, and being African American. Mental health service providers should routinely screen for IPV in men who report histories of CSA and PTSS.

Prevalence of Depressive Symptoms and Correlating Variables Among German Elite Athletes

Depression among elite athletes is a topic of increasing interest, but empirical data are rare. The present study aimed to provide insight into the prevalence of depressive symptoms among German elite athletes and possible associated factors. In an online survey of 162 athletes, we explored depressive symptoms, chronic stress, coping strategies and stress-recovery states. Results indicated an overall prevalence of 15% for depression among elite athletes (n= 99), and revealed higher levels of depressive symptoms among the individual athletes than the team athletes. Furthermore, correlation analyses showed a significant connection between high levels of depressive symptoms and high levels of chronic stress, negative coping strategies and negative stress-recovery states. Results indicate that the prevalence for depressive symptoms in elite athletes is comparable to that in the general German population. Moreover, exploratory analyses provide first indications of factors associated with depressive symptoms.

Physical condition of Black-capped Chickadees (Poecile atricapillus) in relation to road disturbance

Roads and their associated low-frequency noise have been linked with a reduction in abundance and density for many songbird species. However, a handful of species remain equally abundant in roadside habitats and nondisturbed areas. Abundance is a valuable baseline indicator of a species’ ability to adapt to habitats altered by roads, but does not directly ascertain whether health is affected in these species. Here we examine whether Black-capped Chickadees (Poecile atricapillus (L., 1766)), a species that remains abundant near roads, exhibit higher levels of chronic stress or reduced physical condition when residing near roads. Neither hematological measures of chronic stress, nor any of our measures of physical condition, differed significantly between Black-capped Chickadees inhabiting areas near or far from roads. Our results suggest that health and physical condition, like abundance, are not significantly affected by roads in the Black-capped Chickadee. This species may be an ideal model for understanding how some songbird species adapt to roads and the noise that they produce.

Hair Cortisol as a Biomarker of Stress Among a First Nation in Canada

Cortisol level in hair is increasingly being used as a biomarker of chronic stress. Members of First Nation communities in Canada are experiencing stress related to a higher incidence of chronic diseases, socioeconomic factors, the state of their environment, and cultural oppression. This study aimed to investigate hair cortisol as a biomarker of stress in this population. Hair samples were collected from the posterior vertex of 55 Walpole Island First Nation (WIFN) volunteers and compared with white volunteers living in and around London, ON, Canada. An enzyme-linked immunosorbent assay technique was used to measure cortisol content in 1 cm of hair, considered to represent 1 month of growth. In parallel, the Perceived Stress Scale (PSS), which measures short-term stress, was also completed. Median hair cortisol level (range) in WIFN volunteers was 177 (93-273) ng/g, significantly higher than the median hair cortisol in the healthy white controls of 116 (26-204) ng/g (P < 0.0001, Mann-Whitney U test). Hair cortisol correlated positively with gender, smoking status, and self-reported diabetes. Unlike hair cortisol, the Perceived Stress Scale did not differentiate between the First Nation and control population. The increased hair cortisol concentrations among WIFN volunteers compared with volunteers from a non-First Nation community suggests higher levels of chronic stress. The causes for this apparent increased stress are likely due to factors such as socioeconomic and poorer health and are worthy of further evaluation. The results highlight the difference between acute stress measured for short periods of time compared with chronic stress, measured by hair analysis.

Life Events and Stress: Do Older Men and Women in Malaysia Cope Differently as Consumers?

The study of major life events and their effects on well-being has considerable relevance for scientific disciplines and policy making in understanding the consumer behaviour of older people. There is evidence of differences in reactions to and coping with stress between males and females but relatively little knowledge about such gender differences amongst older people, especially in middle-income countries. This study of older Malaysians looked at both coping strategies and gender differences in reactions to stress when people are confronted with certain life events. Seventeen major life events were used in interviews with 645 respondents aged 50years or older in five major urban areas in Peninsular Malaysia. The analysis showed older women tended to experience higher levels of chronic stress than older men. They also had more health problems, had lower levels of self-esteem and were less satisfied with life. Whilst the results showed little support for gender differences in coping behaviours, stress had a significant influence on the way older men and women change store preferences. A hypothesis that older women would use more emotion-focused coping strategies was not supported. Knowledge of how older Malaysians cope with life events and stress and especially in this instance with regard to consumption behaviour, is likely to be of considerable academic and policy related interest.

Level of distress, somatisation and beliefs on health-disease in newly arrived immigrant patients attended in primary care centres in Catalonia and definition of professional competences for their most effective management: PROMISE Project

BackgroundNewly arrived immigrant patients who frequently use primary health care resources have difficulties in verbal communication. Also, they have a system of beliefs related to health and disease that makes difficult for health care professionals to comprehend their reasons for consultation, especially when consulting for somatic manifestations. Consequently, this is an important barrier to achieve optimum care to these groups. The current project has two main objectives: 1. To define the different stressors, the level of distress perceived, and its impact in terms of discomfort and somatisation affecting the main communities of immigrants in our area, and 2. To identify the characteristics of cross-cultural competence of primary health care professionals to best approach these reasons for consultation.Methods/DesignIt will be a transversal, observational, multicentre, qualitative-quantitative study in a sample of 980 people from the five main non-European Union immigrant communities residing in Catalonia: Maghrebis, Sub-Saharans, Andean South Americans, Hindustanis, and Chinese. Sociodemographic data, level of distress, information on the different stressors and their somatic manifestations will be collected in specific questionnaires. Through a semi-structured interview and qualitative methodology, it will be studied the relation between somatic manifestations and particular beliefs of each group and how these are associated with the processes of disease and seeking for care. A qualitative methodology based on individual interviews centred on critical incidents, focal groups and in situ questionnaires will be used to study the cross-cultural competences of the professionals.DiscussionIt is expected a high level of chronic stress associated with the level of somatisations in the different non-European Union immigrant communities. The results will provide better knowledge of these populations and will improve the comprehension and the efficacy of the health care providers in prevention, communication, care management and management of resources.

Abdominal obesity and chronic stress interact to predict blunted cardiovascular reactivity

Abdominal obesity and chronic stress have independent effects on cardiac autonomic regulation, and may also interact to influence cardiovascular reactivity. In addition to main effects, we hypothesized that abdominal obesity and chronic stress would interact and predict blunted cardiovascular reactivity. One hundred and twenty-two undergraduate students engaged in two stressful laboratory tasks while cardiovascular activity was assessed. Results indicated that higher abdominal obesity significantly predicted blunted systolic blood pressure (SBP) and mean arterial pressure (MAP) change, while chronic stress was not directly associated with any measure of cardiovascular reactivity. Furthermore, there was a significant interaction between abdominal obesity and chronic stress on SBP and MAP change such that among participants with higher chronic stress, higher abdominal obesity was significantly associated with reduced SBP and MAP reactivity. In addition, body-mass index (BMI), a measure of overall obesity, also had both main and interaction effects with chronic stress to predict blunted cardiovascular reactivity. These results suggest that abdominally obese individuals may incur difficulty in mounting appropriately-sized cardiovascular responses during acute stress, particularly when under high levels of chronic stress.

Relationship Between Mindfulness-Based Stress Reduction and Immune Function in Cancer and HIV/AIDS

Objective: Chronic stress is widespread, and is detrimental to immune functioning and to overall physical and emotional health. These effects may be potentiated in patients with chronic illness, as high levels of chronic stress are common in this population. Numerous studies support the efficacy of mindfulness-based stress reduction (MBSR) in improving psychological functioning. If a strong relationship is found between MBSR and immune function, then MBSR may be implemented as a strategy to improve immune functioning and overall well-being. Methods: In the present review paper, the relationship between MBSR and immune function is evaluated. Empirical studies measuring immune markers as they relate to a standard MBSR intervention were reviewed. Relevant articles primarily involved patients with cancer or HIV. Therefore, the associations of immune measures with psychological distress are discussed, with an emphasis on patients with these conditions. A psychoneuroimmunological (PNI) framework was utilized to propose a mechanism for the relationship between MBSR and immune function. Results: Overall, the findings support a positive relationship between MBSR intervention and beneficial immunological outcomes. Variability in immune measures assessed across studies precludes pooling data to develop more conclusive results. Conclusions: MBSR has been shown to consistently improve emotional functioning and quality of life, and these effects appear to facilitate immune function.

Abstract A69: The association between chronic stress and telomere length in African American men.

Abstract The telomere is a region of repetitive DNA located at the ends of eukaryotic chromosomes, which protect genetic material from degradation during cellular replication. As a consequence of the inability of DNA polymerase to fully replicate the ends of the chromosome, the telomere progressively shortens as an organism ages. Telomere length in individuals is highly variable, and studies have shown that shortened telomeres are associated with poor prognoses in many diseases, including cancers and other diseases that disproportionately affect American-Americans. There is also strong evidence that environmental and behavioral factors can play an epigenetic role in telomere length homeostasis. Chronic stress is associated with shorter telomeres in women, but studies have not been explicitly done to assess the role of chronic stress in men or minorities. Though there is little evidence of a functional relationship between shortened telomeres and heightened disease states, it is clear that telomeres reflect the health of the individual. We hypothesize that telomere length can be used as a diagnostic indicator of health status, and that the average telomere length are shorter in African-American men due in part to higher levels of chronic stress. To test this hypothesis, we examined the telomere length of DNA from the peripheral blood mononuclear leukocytes of more than 40 African-American men and administered a stress survey to assess chronic stress levels. Preliminary analysis of the data indicates a potential negative association between stress and telomere length, though the results are not significant. We also observed a significant negative correlation between telomere length and body mass index. The results indicate that environmental factors can affect telomere length in African-American men, and that telomere length may be a useful health status indicator in this population. Citation Format: Samantha Simon, Wallace Sharif. The association between chronic stress and telomere length in African American men. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr A69.