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Transfusion dependence is a risk factor for severe infections in myelodysplastic syndromes. Leuk Res 2023; 124:107000. [PMID: 36565489 DOI: 10.1016/j.leukres.2022.107000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/30/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022]
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Ferric Carboxymaltose and Erythropoiesis-Stimulating Agent Treatment Reduces the Rate of Blood Transfusion in Refractory Anemia. J Clin Med 2022; 11:jcm11164744. [PMID: 36012983 PMCID: PMC9410338 DOI: 10.3390/jcm11164744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/05/2022] [Accepted: 08/11/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Erythropoiesis-stimulating agents (ESAs) are used to treat refractory anemia (RA). Guidelines suggest iron supplementation for unresponsive patients, regardless of iron deficiency. The primary aim of this study was to evaluate the effect of iron supplementation with ferric carboxymaltose (FCM) on the reduction of red blood cell transfusion (RBCT) rate in transfusion-dependent RA patients. Methods: This was a prospective quasi-randomized study, wherein patients were randomly assigned into three groups: (A) ESAs alone, (B) ferric gluconate (FG) and ESAs, and (C) FCM and ESAs. Hemoglobin and ferritin levels, as well as the number of RBCTs at 4 and 28 weeks were compared. Economic evaluation was also performed. Results: A total of 113 RA patients were enrolled. In total, 43 were treated with intravenous FG and ESAs, 38 with FCM and ESAs, and 32 with ESAs alone. At both follow-ups, erythropoietic response was increased in those receiving iron as compared with those with ESAs alone (p = 0.001), regardless of the type of iron. At one month, ferritin levels were higher in the FCM and ESA groups (p = 0.001). RBCTs were lower in both iron groups. The less costly treatment strategy was FCM, followed by FG, and lastly ESAs. Conclusions: Addition of iron to ESAs in RA reduced RBCT requirement and improved hemoglobin values.
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Uman N, Kobbuaklee S, Kansuwan P, Watanaboonyongcharoen P, Polprasert C. Detection of Red Blood Cell Membrane Proteins in Myelodysplastic Syndromes Using Eosin-5-Maleimide (EMA) Staining by Flow Cytometry. Hematol Rep 2022; 14:13-18. [PMID: 35323174 PMCID: PMC8955372 DOI: 10.3390/hematolrep14010003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 02/16/2022] [Accepted: 02/24/2022] [Indexed: 11/21/2022] Open
Abstract
Background: Eosin-5-Maleimide (EMA)-based flow cytometry binds to red blood cell (RBC) membrane-associated proteins which can be used to detect red blood cell (RBC) membrane disorders. Myelodysplastic syndromes (MDS) are stem cell disorders resulting in ineffective hematopoiesis which is commonly present with anemia and erythroid dysplasia. Objectives: We aimed to study RBC membrane defects in MDS using flow cytometry for EMA staining. Methods: We enrolled anemic patients who were diagnosed with low-risk MDS (R-IPSS score ≤ 3.5), RBC membrane disorders [hereditary spherocytosis (HS) and Southeast Asian ovalocytosis (SAO)], and normal controls. Complete blood count (CBC) and flow cytometry for EMA staining were performed. Results: There were 16 cases of low-risk MDS, 6 cases of RBC membrane disorders, and 15 control cases. Mean fluorescence intensity (MFI) of EMA binding test in the RBC membrane disorders was significantly lower than controls (17.6 vs. 24.3, p < 0.001), but the EMA binding test in the low-risk MDS was not significantly different than the controls (26.5 vs. 24.3, p = 0.08). Conclusion: the RBC membrane defect in low-risk MDS was not demonstrated as having detection ability using EMA binding test with flow cytometry.
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Affiliation(s)
- Navavee Uman
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10230, Thailand
| | - Sirorat Kobbuaklee
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10230, Thailand
- Research Unit in Translational Hematology, Chulalongkorn University, Bangkok 10230, Thailand
| | - Patsita Kansuwan
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10230, Thailand
| | - Phandee Watanaboonyongcharoen
- Department of Clinical Pathology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10230, Thailand
| | - Chantana Polprasert
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10230, Thailand
- Research Unit in Translational Hematology, Chulalongkorn University, Bangkok 10230, Thailand
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Alonso-Fernandez-Gatta M, Martin-Garcia A, Martin-Garcia AC, Lopez-Cadenas F, Diaz-Pelaez E, Jimenez-Solas T, Gonzalez-Martinez T, Sanchez-Pablo C, Diez-Campelo M, Sanchez PL. Predictors of cardiovascular events and all-cause of death in patients with transfusion-dependent myelodysplastic syndrome. Br J Haematol 2021; 195:536-541. [PMID: 34180544 DOI: 10.1111/bjh.17652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 01/06/2021] [Indexed: 11/30/2022]
Abstract
Cardiovascular disease (CVD) involves the second cause of death in low-risk myelodysplastic syndrome (MDS) population. Prospective study to characterise the CVD and to identify predictors for the combined event (CE) cardiovascular event and/or all-cause mortality in transfusion dependent low-risk MDS patients. Thirty-one patients underwent a cardiac assessment including biomarkers and cardiac magnetic resonance (cMR) with parametric sequences (T1, T2 and T2* mapping) and myocardial deformation by feature tracking (FT) and were analysed for clonal hematopoiesis of indeterminate potential mutations. Cardiac assessment revealed high prevalence of unknown structural heart disease (51% cMR pathological findings). After 2·2 [0·44] years follow-up, 35·5% of patients suffered the CE: 16% death, 29% cardiovascular event. At multivariate analysis elevated NT-proBNP ≥ 486pg/ml (HR 96·7; 95%-CI 1·135-8243; P = 0·044), reduced native T1 time < 983ms (HR 44·8; 95%-CI 1·235-1623; P = 0·038) and higher left ventricular global longitudinal strain (LV-GLS) (HR 0·4; 95%-CI 0·196-0·973; P = 0·043) showed an independent prognostic value. These variables, together with the myocardial T2* time < 20ms, showed an additive prognostic value (Log Rank: 12·4; P = 0·001). In conclusion, low-risk MDS patients frequently suffer CVD. NT-proBNP value, native T1 relaxation time and longitudinal strain by FT are independent predictors of poor cardiovascular prognosis, thus, their determination would identify high-risk patients who could benefit from a cardiac treatment and follow-up.
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Affiliation(s)
| | - Ana Martin-Garcia
- Cardiology Department, University Hospital of Salamanca, IBSAL, CIBER-CV (ISCiii), Salamanca, Spain
| | - Agustin C Martin-Garcia
- Cardiology Department, University Hospital of Salamanca, IBSAL, CIBER-CV (ISCiii), Salamanca, Spain
| | - Felix Lopez-Cadenas
- Hematology Department, University Hospital of Salamanca, IBSAL, Salamanca, Spain
| | - Elena Diaz-Pelaez
- Cardiology Department, University Hospital of Salamanca, IBSAL, CIBER-CV (ISCiii), Salamanca, Spain
| | - Tamara Jimenez-Solas
- Hematology Department, University Hospital of Salamanca, IBSAL, Salamanca, Spain
| | | | - Clara Sanchez-Pablo
- Cardiology Department, University Hospital of Salamanca, IBSAL, CIBER-CV (ISCiii), Salamanca, Spain
| | - Maria Diez-Campelo
- Hematology Department, University Hospital of Salamanca, IBSAL, Salamanca, Spain
| | - Pedro L Sanchez
- Cardiology Department, University Hospital of Salamanca, IBSAL, CIBER-CV (ISCiii), Salamanca, Spain
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Pavlidis G, Papageorgiou SG, Bazani E, Bouchla A, Glezou E, Gkontopoulos K, Thomopoulos T, Pappa V, Vlahakos DV. Discontinuation of the renin-angiotensin system inhibitors improves erythropoiesis in patients with lower-risk myelodysplastic syndromes. Ther Adv Hematol 2021; 12:2040620720958299. [PMID: 33489062 PMCID: PMC7809530 DOI: 10.1177/2040620720958299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/20/2020] [Indexed: 11/15/2022] Open
Abstract
Renin–angiotensin system (RAS) blockade by angiotensin-converting enzyme inhibitors (ACEis) or angiotensin-receptor blockers (ARBs) has been related to anemia in various situations. We aimed to investigate whether discontinuation of RAS inhibitors improves erythropoiesis in patients with lower-risk myelodysplastic syndromes (LR-MDSs). Seventy-four patients with LR-MDS were divided into three groups matched for gender and age. Group A consisted of 20 hypertensive patients who discontinued RAS inhibitors and received alternative medications. Group B consisted of 26 patients who continued to receive ACEi/ARB and Group C included 28 patients (50% hypertensive) never exposed to ACEi/ARB. Half of the patients in each group were under treatment with recombinant human erythropoietin (rHuEPO). Data were collected at baseline and after 3, 6 and 12 months. Group A showed a significant increase in hemoglobin from 10.4 ± 1g/dL at baseline to 12.6 ± 1.2 g/dL after 12 months (p = 0.035) and in hematocrit (31.4 ± 3% versus 37.9 ± 4%, p = 0.002). Incident anemia decreased from 100% at baseline to 60% at 12 months (p = 0.043) despite a concomitant dose reduction in rHuEPO by 18% (p = 0.035). No changes in hemoglobin and hematocrit were observed in both Group B and Group C. In the subset of patients not treated with rHuEPO, improvement of erythropoiesis was found only in Group A, as measured by changes in hemoglobin (11.5 ± 1 g/dL versus 12.4 ± 1.3 g/dL, p = 0.041) and hematocrit (34.5 ± 3% versus 37.1 ± 4%, p = 0.038) after 12 months. In contrast, Group B and Group C decreased hemoglobin and hematocrit after 12 months (p < 0.05). In conclusion, discontinuation of ACEi/ARB in LR-MDS patients is followed by a significant recovery of erythropoiesis after 12 months.
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Affiliation(s)
- George Pavlidis
- 2nd Department of Internal Medicine - Propaedeutic and Research Unit, National and Kapodistrian University of Athens, Medical School, University General Hospital "Attikon", Athens, Greece
| | - Sotirios G Papageorgiou
- 2nd Department of Internal Medicine - Propaedeutic and Research Unit, National and Kapodistrian University of Athens, Medical School, University General Hospital "Attikon", 1 Rimini St., Haidari, Athens, 12462, Greece
| | - Efthimia Bazani
- 2nd Department of Internal Medicine - Propaedeutic and Research Unit, National and Kapodistrian University of Athens, Medical School, University General Hospital "Attikon", Athens, Greece
| | - Anthi Bouchla
- 2nd Department of Internal Medicine - Propaedeutic and Research Unit, National and Kapodistrian University of Athens, Medical School, University General Hospital "Attikon", Athens, Greece
| | - Eirini Glezou
- 2nd Department of Internal Medicine - Propaedeutic and Research Unit, National and Kapodistrian University of Athens, Medical School, University General Hospital "Attikon", Athens, Greece
| | - Konstantinos Gkontopoulos
- 2nd Department of Internal Medicine - Propaedeutic and Research Unit, National and Kapodistrian University of Athens, Medical School, University General Hospital "Attikon", Athens, Greece
| | - Thomas Thomopoulos
- 2nd Department of Internal Medicine - Propaedeutic and Research Unit, National and Kapodistrian University of Athens, Medical School, University General Hospital "Attikon", Athens, Greece
| | - Vasiliki Pappa
- 2nd Department of Internal Medicine - Propaedeutic and Research Unit, National and Kapodistrian University of Athens, Medical School, University General Hospital "Attikon", Athens, Greece
| | - Demetrios V Vlahakos
- 2nd Department of Internal Medicine - Propaedeutic and Research Unit, National and Kapodistrian University of Athens, Medical School, University General Hospital "Attikon", Athens, Greece
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Brownstein CG, Daguenet E, Guyotat D, Millet GY. Chronic fatigue in myelodysplastic syndromes: Looking beyond anemia. Crit Rev Oncol Hematol 2020; 154:103067. [PMID: 32739782 DOI: 10.1016/j.critrevonc.2020.103067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 07/10/2020] [Accepted: 07/23/2020] [Indexed: 12/11/2022] Open
Abstract
Chronic fatigue is the most common and severe symptom in myelodysplastic syndromes (MDS) and has a strong negative association with health-related quality of life (HRQoL). Despite anemia being the most common objective manifestation of MDS, and the associated link between anemia and fatigue, evidence on treatments which temporarily mitigate anemia is equivocal regarding the effects on fatigue. Furthermore, previous work has found weak associations between anemia and chronic fatigue in MDS. As such, given that improving HRQoL is one of the primary treatment aims in MDS, further work is required to identify other potential contributors to chronic fatigue in these patients. In addition to anemia, MDS is associated with numerous other deviations in physiological homeostasis and has negative psychological consequences with links to chronic fatigue. Accordingly, the present review provides several potential aetiologic agents relevant to chronic fatigue in MDS which can be used to guide future research in this field.
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Affiliation(s)
- Callum G Brownstein
- Univ Lyon, UJM-Saint-Etienne, Inter-University Laboratory of Human Movement Biology, EA 7424, F-42023, Saint-Etienne, France.
| | - Elisabeth Daguenet
- Lucien Neuwirth Cancer Institute, Hematology and Cell Therapy, F-42271 Saint-Priest-en-Jarez, France; Lucien Neuwirth Cancer Institute, Research and Teaching Department, F-42271 Saint-Priest-en-Jarez, France
| | - Denis Guyotat
- Lucien Neuwirth Cancer Institute, Hematology and Cell Therapy, F-42271 Saint-Priest-en-Jarez, France; UMR 5239 Laboratoire de Biologie et Modélisation de la Cellule, Ecole Normale Supérieure, Lyon, France
| | - Guillaume Y Millet
- Univ Lyon, UJM-Saint-Etienne, Inter-University Laboratory of Human Movement Biology, EA 7424, F-42023, Saint-Etienne, France; Institut Universitaire de France (IUF), France
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Angelucci E, Li J, Greenberg P, Wu D, Hou M, Montano Figueroa EH, Rodriguez MG, Dong X, Ghosh J, Izquierdo M, Garcia-Manero G. Iron Chelation in Transfusion-Dependent Patients With Low- to Intermediate-1-Risk Myelodysplastic Syndromes: A Randomized Trial. Ann Intern Med 2020; 172:513-522. [PMID: 32203980 DOI: 10.7326/m19-0916] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Iron chelation therapy (ICT) in patients with lower-risk myelodysplastic syndromes (MDS) has not been evaluated in randomized studies. OBJECTIVE To evaluate event-free survival (EFS) and safety of ICT in iron-overloaded patients with low- or intermediate-1-risk MDS. DESIGN Multicenter, randomized, double-blind, placebo-controlled trial (TELESTO). (ClinicalTrials.gov: NCT00940602). SETTING 60 centers in 16 countries. PARTICIPANTS 225 patients with serum ferritin levels greater than 2247 pmol/L; prior receipt of 15 to 75 packed red blood cell units; and no severe cardiac, liver, or renal abnormalities. INTERVENTION Deferasirox dispersible tablets (10 to 40 mg/kg per day) (n = 149) or matching placebo (n = 76). MEASUREMENTS The primary end point was EFS, defined as time from date of randomization to first documented nonfatal event (related to cardiac or liver dysfunction and transformation to acute myeloid leukemia) or death, whichever occurred first. RESULTS Median time on treatment was 1.6 years (interquartile range [IQR], 0.5 to 3.1 years) in the deferasirox group and 1.0 year (IQR, 0.6 to 2.0 years) in the placebo group. Median EFS was prolonged by approximately 1 year with deferasirox versus placebo (3.9 years [95% CI, 3.2 to 4.3 years] vs. 3.0 years [CI, 2.2 to 3.7 years], respectively; hazard ratio, 0.64 [CI, 0.42 to 0.96]). Adverse events occurred in 97.3% of deferasirox recipients and 90.8% of placebo recipients. Exposure-adjusted incidence rates of adverse events (≥15 events per 100 patient treatment-years) in deferasirox versus placebo recipients, respectively, were 24.7 versus 23.9 for diarrhea, 21.8 versus 18.7 for pyrexia, 16.7 versus 22.7 for upper respiratory tract infection, and 15.9 versus 0.9 for increased serum creatinine concentration. LIMITATIONS The protocol was amended from a phase 3 to a phase 2 study, with a reduced target sample size from 630 to 210 participants. There was differential follow-up between treatment groups. CONCLUSION The findings support ICT in iron-overloaded patients with low- to intermediate-1-risk MDS, with longer EFS compared with placebo and a clinically manageable safety profile. Therefore, ICT may be considered in these patients. PRIMARY FUNDING SOURCE Novartis Pharma AG.
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Affiliation(s)
- Emanuele Angelucci
- Hematology and Transplant Center, IRCCS Ospedale Policlinico San Martino, Genova, Italy (E.A.)
| | - Junmin Li
- Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China (J.L.)
| | - Peter Greenberg
- Stanford University Medical Center, Stanford, California (P.G.)
| | - Depei Wu
- Jiangsu Institute of Hematology, First Affiliated Hospital of Soochow University, Suzhou, China (D.W.)
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China (M.H.)
| | | | - Maria Guadalupe Rodriguez
- Department of Hematology, Hospital de Especialidades, Centro Médico Nacional La Raza, IMSS, Mexico City, Mexico (M.G.R.)
| | - Xunwei Dong
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey (X.D., J.G.)
| | - Jagannath Ghosh
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey (X.D., J.G.)
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Cernaro V, Coppolino G, Visconti L, Rivoli L, Lacquaniti A, Santoro D, Buemi A, Loddo S, Buemi M. Erythropoiesis and chronic kidney disease-related anemia: From physiology to new therapeutic advancements. Med Res Rev 2018; 39:427-460. [PMID: 30084153 DOI: 10.1002/med.21527] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 06/18/2018] [Accepted: 07/06/2018] [Indexed: 12/19/2022]
Abstract
Erythropoiesis is triggered by hypoxia and is strictly regulated by hormones, growth factors, cytokines, and vitamins to ensure an adequate oxygen delivery to all body cells. Abnormalities in one or more of these factors may induce different kinds of anemia requiring different treatments. A key player in red blood cell production is erythropoietin. It is a glycoprotein hormone, mainly produced by the kidneys, that promotes erythroid progenitor cell survival and differentiation in the bone marrow and regulates iron metabolism. A deficit in erythropoietin synthesis is the main cause of the normochromic normocytic anemia frequently observed in patients with progressive chronic kidney disease. The present review summarizes the most recent findings about each step of the erythropoietic process, going from the renal oxygen sensing system to the cascade of events induced by erythropoietin through its own receptor in the bone marrow. The paper also describes the new class of drugs designed to stabilize the hypoxia-inducible factor by inhibiting prolyl hydroxylase, with a discussion about their metabolism, disposition, efficacy, and safety. According to many trials, these drugs seem able to simulate tissue hypoxia and then stimulate erythropoiesis in patients affected by renal impairment. In conclusion, the in-depth investigation of all events involved in erythropoiesis is crucial to understand anemia pathophysiology and to identify new therapeutic strategies, in an attempt to overcome the potential side effects of the commonly used erythropoiesis-stimulating agents.
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Affiliation(s)
- Valeria Cernaro
- Chair of Nephrology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giuseppe Coppolino
- Nephrology and Dialysis Unit, Department of Internal Medicine, "Pugliese-Ciaccio" Hospital of Catanzaro, Catanzaro, Italy
| | - Luca Visconti
- Chair of Nephrology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Laura Rivoli
- Unit of Nephrology, Department of Internal Medicine, Chivasso Hospital, Turin, Italy
| | - Antonio Lacquaniti
- Chair of Nephrology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Domenico Santoro
- Chair of Nephrology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Antoine Buemi
- Surgery and Abdominal Transplantation Division, Cliniques Universitaires Saint-Luc, Université Catholique De Louvain, Brussels, Belgium
| | - Saverio Loddo
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Michele Buemi
- Chair of Nephrology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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