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Upadhyay UD, Koenig LR, Meckstroth K, Ko J, Valladares ES, Biggs MA. Effectiveness and safety of telehealth medication abortion in the USA. Nat Med 2024; 30:1191-1198. [PMID: 38361123 PMCID: PMC11031403 DOI: 10.1038/s41591-024-02834-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/24/2024] [Indexed: 02/17/2024]
Abstract
Telehealth abortion has become critical to addressing surges in demand in states where abortion remains legal but evidence on its effectiveness and safety is limited. California Home Abortion by Telehealth (CHAT) is a prospective study that follows pregnant people who obtained medication abortion via telehealth from three virtual clinics operating in 20 states and Washington, DC between April 2021 and January 2022. Individuals were screened using a standardized no-test protocol, primarily relying on their medical history to assess medical eligibility. We assessed effectiveness, defined as complete abortion after 200 mg mifepristone and 1,600 μg misoprostol (or lower) without additional intervention; safety was measured by the absence of serious adverse events. We estimated rates using multivariable logistic regression and multiple imputation to account for missing data. Among 6,034 abortions, 97.7% (95% confidence interval (CI) = 97.2-98.1%) were complete without subsequent known intervention or ongoing pregnancy after the initial treatment. Overall, 99.8% (99.6-99.9%) of abortions were not followed by serious adverse events. In total, 0.25% of patients experienced a serious abortion-related adverse event, 0.16% were treated for an ectopic pregnancy and 1.3% abortions were followed by emergency department visits. There were no differences in effectiveness or safety between synchronous and asynchronous models of care. Telehealth medication abortion is effective, safe and comparable to published rates of in-person medication abortion care.
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Affiliation(s)
- Ushma D Upadhyay
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA.
| | - Leah R Koenig
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Karen Meckstroth
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Jennifer Ko
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | | | - M Antonia Biggs
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
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Rosenberg JD, Raymond E, Shochet T. An examination of loss to follow-up and potential bias in outcome ascertainment in a study of direct-to-patient telemedicine abortion in the United States. Contraception 2023; 122:109996. [PMID: 36841460 DOI: 10.1016/j.contraception.2023.109996] [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: 08/23/2022] [Revised: 02/15/2023] [Accepted: 02/19/2023] [Indexed: 02/26/2023]
Abstract
OBJECTIVES To examine associations between factors associated with loss to follow-up and effectiveness in the TelAbortion project, which provided medication abortion by direct-to-patient telemedicine and mail in the United States. STUDY DESIGN The study population for this descriptive analysis included abortions among participants enrolled in the TelAbortion study with data present in a web-based database tool from November 2018 to September 2021 who were mailed a medication package. The analysis included information on abortions across nine sites. In this analysis, we used generalized estimating equations to examine factors associated with loss to follow-up and effectiveness. RESULTS Of the 1831 abortions included in this analysis, 1553 (84.8%) were classified as having complete follow-up and 278 (15.2%) were classified as lost to follow-up. In a multivariable analysis, factors significantly associated with loss to follow-up included history of medical abortion, education, gestational age, study site, and whether the TelAbortion was performed pre- or post-COVID-19 onset (p < 0.05). The rate of treatment failure (i.e., abortions resulting in continuing pregnancy or uterine evacuation) reported in this study was 5.1%. The only covariate associated with both loss to follow-up and treatment failure was higher gestational age. However, using gestational age to impute missing abortion outcomes did not substantially change the estimated failure rate. CONCLUSIONS Abortions that were lost to follow-up differed substantially from those with complete follow-up, which could bias the effectiveness estimate. However, imputing outcomes based on available and appropriate pretreatment data did not substantially affect the estimate. This finding is encouraging, although it does not exclude the possibility of bias due to unmeasured factors. IMPLICATIONS Significant differences between abortion cases with complete follow-up and those lost to follow-up provide insights into abortion cases that may be at a higher risk for being lost. The low treatment failure rate indicates that the telemedicine provision of medication abortion is effective.
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Affiliation(s)
- Jessica D Rosenberg
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA; Guttmacher Institute, New York, NY, USA.
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Comparison of vaginal and buccal misoprosotol after mifepristone for medication abortion through 70 days of gestation: A retrospective chart review. Contraception 2022; 115:62-66. [DOI: 10.1016/j.contraception.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 06/16/2022] [Accepted: 06/20/2022] [Indexed: 11/22/2022]
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Anger H, Dabash R, Peña M, Coutiño D, Bousiéguez M, Sanhueza P, Winikoff B. Use of an at-home multilevel pregnancy test and an automated call-in system to follow-up the outcome of medical abortion. Int J Gynaecol Obstet 2018; 144:97-102. [DOI: 10.1002/ijgo.12679] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 07/10/2018] [Accepted: 09/14/2018] [Indexed: 11/11/2022]
Affiliation(s)
| | | | | | - Dolores Coutiño
- Hospital Materno-Infantil Nicolás M. Cedillo; Secretariat of Health; Mexico City Mexico
| | | | - Patricio Sanhueza
- Department of Reproductive Health; Secretariat of Health; Mexico City Mexico
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Laursen L, Stumbras K, Lewnard I, Haider S. Contraceptive Provision after Medication and Surgical Abortion. Womens Health Issues 2017; 27:546-550. [DOI: 10.1016/j.whi.2017.03.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 03/21/2017] [Accepted: 03/24/2017] [Indexed: 11/16/2022]
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Bettahar K, Pinton A, Boisramé T, Cavillon V, Wylomanski S, Nisand I, Hassoun D. Interruption volontaire de grossesse par voie médicamenteuse. ACTA ACUST UNITED AC 2016; 45:1490-1514. [DOI: 10.1016/j.jgyn.2016.09.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 09/26/2016] [Accepted: 09/27/2016] [Indexed: 10/20/2022]
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Wood SF, Borkowski L, Strasser J, Allina A. For Medication Abortion, Science Should Guide Policy. Womens Health Issues 2016; 26:357-60. [PMID: 27234213 DOI: 10.1016/j.whi.2016.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 04/11/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Susan F Wood
- Jacobs Institute of Women's Health, Milken Institute School of Public Health, George Washington University, Washington, DC; Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University, Washington, DC.
| | - Liz Borkowski
- Jacobs Institute of Women's Health, Milken Institute School of Public Health, George Washington University, Washington, DC; Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Julia Strasser
- Jacobs Institute of Women's Health, Milken Institute School of Public Health, George Washington University, Washington, DC; Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Amy Allina
- Jacobs Institute of Women's Health, Milken Institute School of Public Health, George Washington University, Washington, DC
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Abstract
OBJECTIVE This guideline reviews the evidence relating to the provision of first-trimester medical induced abortion, including patient eligibility, counselling, and consent; evidence-based regimens; and special considerations for clinicians providing medical abortion care. INTENDED USERS Gynaecologists, family physicians, registered nurses, midwives, residents, and other healthcare providers who currently or intend to provide pregnancy options counselling, medical abortion care, or family planning services. TARGET POPULATION Women with an unintended first trimester pregnancy. EVIDENCE Published literature was retrieved through searches of PubMed, MEDLINE, and Cochrane Library between July 2015 and November 2015 using appropriately controlled vocabulary (MeSH search terms: Induced Abortion, Medical Abortion, Mifepristone, Misoprostol, Methotrexate). Results were restricted to systematic reviews, randomized controlled trials, clinical trials, and observational studies published from June 1986 to November 2015 in English. Additionally, existing guidelines from other countries were consulted for review. A grey literature search was not required. VALUES The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force for Preventive Medicine rating scale (Table 1). BENEFITS, HARMS AND/OR COSTS Medical abortion is safe and effective. Complications from medical abortion are rare. Access and costs will be dependent on provincial and territorial funding for combination mifepristone/misoprostol and provider availability. SUMMARY STATEMENTS Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care RECOMMENDATIONS Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care.
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Comparing office and telephone follow-up after medical abortion. Contraception 2016; 94:122-6. [PMID: 27101901 DOI: 10.1016/j.contraception.2016.04.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 04/11/2016] [Accepted: 04/12/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Compare proportion lost to follow-up, successful abortion, and staff effort in women who choose office or telephone-based follow-up evaluation for medical abortion at a teaching institution. STUDY DESIGN We performed a chart review of all medical abortions provided in the first three years of service provision. Women receiving mifepristone and misoprostol could choose office follow-up with an ultrasound evaluation one to two weeks after mifepristone or telephone follow-up with a scheduled telephone interview at one week post abortion and a second telephone call at four weeks to review the results of a home urine pregnancy test. RESULTS Of the 176 medical abortion patients, 105 (59.7%) chose office follow-up and 71 (40.3%) chose telephone follow-up. Office evaluation patients had higher rates of completing all required follow-up compared to telephone follow-up patients (94.3% vs 84.5%, respectively, p=.04), but proportion lost to follow-up was similar in both groups (4.8% vs 5.6%, respectively, p=1.0). Medical abortion efficacy was 94.0% and 92.5% in women who chose office and telephone follow-up, respectively. We detected two (1.2%) ongoing pregnancies, both in the office group. Staff rescheduled 15.0% of appointments in the office group. For the telephone follow-up cohort, staff made more than one phone call to 43.9% and 69.4% of women at one week and four weeks, respectively. CONCLUSIONS Proportion lost to follow-up is low in women who have the option of office or telephone follow-up after medical abortion. Women who choose telephone-based evaluation compared to office follow-up may require more staff effort for rescheduling of contact, but overall outcomes are similar. IMPLICATIONS Although women who choose telephone evaluation may require more rescheduling of contact as compared to office follow-up, having alternative follow-up options may decrease the proportion of women who are lost to follow-up.
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Dunn S, Panjwani D, Gupta M, Meaney C, Morgan R, Feuerstein E. Comparison of remote and in-clinic follow-up after methotrexate/misoprostol abortion. Contraception 2015; 92:220-6. [PMID: 26068140 DOI: 10.1016/j.contraception.2015.05.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 05/26/2015] [Accepted: 05/31/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE This study compared adherence to follow-up and clinical outcomes between standard in-clinic and remote follow-up after methotrexate/misoprostol abortion. STUDY DESIGN This nonrandomized trial recruited women requesting medical abortion at two sexual health clinics in Toronto, Canada. Women received methotrexate 50 mg/m(2) followed 3-7 days later by 800 mcg of misoprostol self-administered vaginally. For Day 15, follow-up participants could choose standard in-clinic follow-up with ultrasound and assessment or remote telephone follow-up with serum β-hCG performed at a community laboratory and symptom checklist. Standard and remote follow-up groups were compared for adherence, defined as completing follow-up within 7 days of the scheduled time, and clinical outcomes. Characteristics associated with adherence were assessed using multivariable logistic regression. RESULTS Of 129 women, 86 (67%) chose remote follow-up. Nonadherence rates for remote (28%) and standard (23%) follow-up groups did not differ in univariate (p=.57) or multivariable analysis (odds ratio: 1.09, 95% confidence interval: 0.39-3.01). Rates of emergency/hospital visits were 3% and 9% for remote and standard groups, respectively (p=.22), and complete loss to follow was 6% and 14% in remote and standard groups (p=.18). Nonadherent women were more likely to be undecided about their contraception (65% vs. 28%; p=.002), and this difference persisted in the multivariable analysis. CONCLUSION Given a choice of remote or in-clinic follow-up after methotrexate/misoprostol abortion, most women chose remote follow-up. Rates of adherence to follow-up, adverse outcomes and complete loss to follow-up were similar for women choosing remote and standard follow-up. IMPLICATIONS STATEMENT Since standard and remote follow-up after methotrexate/misoprostol abortion are associated with similar adherence to follow-up and similar safety profiles, women should be offered their choice of follow-up method.
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Affiliation(s)
- Sheila Dunn
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada; Women's College Hospital, Toronto, ON, Canada; Women's College Research Institute, Toronto, ON, Canada.
| | | | - Melini Gupta
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Christopher Meaney
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.
| | | | - Erika Feuerstein
- Women's College Hospital, Toronto, ON, Canada; Choice in Health Clinic, Toronto, ON, Canada.
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Early serum human chorionic gonadotropin (hCG) trends after medication abortion. Contraception 2015; 91:503-6. [PMID: 25765358 DOI: 10.1016/j.contraception.2015.03.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 03/02/2015] [Accepted: 03/03/2015] [Indexed: 01/20/2023]
Abstract
OBJECTIVES Despite increased reliance on human chorionic gonadotropin (hCG) for early pregnancy monitoring, there is limited information about hCG trends soon after medication abortion. The purpose of this study was to determine if there is a predictable decline in serum hCG values shortly after medication abortion. STUDY DESIGN This is a retrospective study of women with early intrauterine pregnancies who underwent medication abortion with mifepristone and misoprostol and had a serum hCG level on Day 1 (day of mifepristone) and a repeat value on Day 2 to 6. The percent hCG decline was calculated from baseline to repeat measure, with repeat values from the same patient accounted for through repeated measure analysis of variance. RESULTS Eighty-eight women with a mean gestational age of 5.5 weeks and median baseline hCG of 5220 IU met study criteria over a 3-year period. The mean decline (±SD) in hCG from the Day 1 baseline value was 56.9%±29.5% on Day 3, 73.5%±38.6% on Day 4, 86.1%±8.8% on Day 5, and 92.9%±3.4% on Day 6. Eighty-two women (93% of the cohort) had a complete abortion without further intervention. The least square means hCG decline among these women was 57.6% [95% confidence interval (CI): 50.3-64.9%] on Day 3, 78.9% (95% CI: 75.0-82.8%) on Day 4 and 86.2% (95% CI: 81.3-91.1%) on Day 5. CONCLUSION There is a rapid decline in serum hCG within the first few days after early medication abortion. Further research is needed to delineate how soon after medication abortion this decline may be specific enough to confirm abortion completion. IMPLICATIONS This study provides the largest cohort of patients followed with serial hCG values in the first few days after medication abortion. Our findings demonstrate the trend in hCG decline in this population, which may be predictable by Day 5.
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Acceptability and feasibility of phone follow-up with a semiquantitative urine pregnancy test after medical abortion in Moldova and Uzbekistan. Contraception 2015; 91:178-83. [DOI: 10.1016/j.contraception.2014.11.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 10/31/2014] [Accepted: 11/04/2014] [Indexed: 11/19/2022]
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Gatter M, Cleland K, Nucatola DL. Efficacy and safety of medical abortion using mifepristone and buccal misoprostol through 63 days. Contraception 2015; 91:269-73. [PMID: 25592080 DOI: 10.1016/j.contraception.2015.01.005] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 01/07/2015] [Accepted: 01/07/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this study was to report on the safety and efficacy of an evidence-based medical abortion regimen utilizing 200 mg of mifepristone orally followed by home use of 800 mcg misoprostol buccally 24-48 h later through 63 days estimated gestational age. STUDY DESIGN We analyzed outcomes in women presenting for medical abortion between April 1, 2006, and May 31, 2011, using an evidence-based alternative to the United States Food and Drug Administration (FDA)-approved regimen. Cases were identified for this descriptive study from our electronic practice management (EPM) database, and our electronic database on adverse events was queried for information on efficacy and safety. The primary outcome was successful abortion. Logistic regression was used to identify predictors of successful abortion. RESULTS Among the 13,373 women who completed follow-up, efficacy of the regimen was 97.7%. Efficacy was highest at 29 to 35 days (98.8%) and 36 to 42 days (98.8%) of gestation and lowest at 57 to 63 days (95.5%). The odds of needing aspiration for any reason were greatest at higher gestational ages. Rates of infection requiring hospitalization and rates of transfusion were 0.01 and 0.03%, respectively. CONCLUSIONS An evidence-based regimen of 200 mg of mifepristone orally followed by home use of 800 mcg of buccal misoprostol 24-48 h later is safe and effective through 63 days estimated gestational age. Further, the need for aspiration for any reason was low, and hospitalization was rare. IMPLICATIONS This study reinforces the safety and efficacy of the evidence-based regimen for medical abortion (200 mg mifepristone orally followed by home use of 800 mcg of misoprostol buccally 24-48 h later) through 63 days estimated gestational age, and contributes to the existing evidence against restrictions requiring use of the FDA-approved regimen.
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Affiliation(s)
- Mary Gatter
- Planned Parenthood Los Angeles, 400 West 30th St., Los Angeles, CA 90007
| | - Kelly Cleland
- 218 Wallace Hall, Office of Population Research, Princeton University, Princeton, NJ 08544
| | - Deborah L Nucatola
- Planned Parenthood Los Angeles, 400 West 30th St., Los Angeles, CA 90007.
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Medical abortion follow-up with serum human chorionic gonadotropin compared with ultrasonography: a randomized controlled trial. Obstet Gynecol 2013; 121:607-613. [PMID: 23635625 DOI: 10.1097/aog.0b013e3182839fda] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To estimate whether follow-up with serum human chorionic gonadotropin (hCG) results in fewer unplanned visits and interventions than follow-up with ultrasonography. METHODS Women were randomized to either in-clinic serum hCG or ultrasound follow-up after medical abortion. The primary outcome, unplanned interventions and visits, was measured as a composite binary outcome including: additional clinic or emergency room visits, repeat dosing of misoprostol, and surgical evacuation of the uterus. Surveys were administered at initial follow-up and again 1 month after abortion to inquire about unscheduled visits, interventions, and patient satisfaction. Medical records were reviewed for evidence of additional interventions and visits. RESULTS A total of 376 patients was randomized. Most participants were white (56%), single (83%), nulliparous (63%), and had completed high school (96%). Average participant age was 26±6 years and average gestational age was 46±6 days. Within 2 weeks of abortion, there was no significant difference in the rate of unplanned interventions and visits between arms, 8.2% (13/159) in the serum hCG arm compared with 6.6% (10/151) in the ultrasound arm (relative risk 1.23, 95% confidence interval [CI] 0.56-2.73, P=.60). By 4 weeks postabortion, 4.4% (6/135) in the ultrasound arm and 1.4% (2/142) in the hCG arm had undergone surgical evacuation (relative risk 0.32, 95% CI 0.07-1.54, P=.16). The majority in both the serum hCG (88%) and ultrasound (95%) arms was satisfied with their assigned follow-up method. CONCLUSION Medical abortion follow-up with serum hCG does not reduce the rate of unplanned interventions and visits compared with ultrasonography. Overall, the number of unplanned interventions is low and both methods of follow-up are acceptable to women.
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