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Ross LA, Lee J, Carlson AK, Conway DS, Cohen JA, Graves J, Zamvil SS, Newsome SD, Kunchok A. Progressive Encephalomyelopathy in an Older Man: A Case Report From the National Multiple Sclerosis Society Case Conference Proceedings. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200210. [PMID: 38386951 PMCID: PMC10900913 DOI: 10.1212/nxi.0000000000200210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 01/12/2024] [Indexed: 02/24/2024]
Abstract
We present a case of subacute onset progressive encephalomyelopathy in a 77-year-old man with symmetric lateral column signal abnormalities on spinal MRI. We discuss the differential and presumptive final diagnosis along with a review of the postulated disease immunopathogenesis.
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Affiliation(s)
- Lindsay A Ross
- From the Mellen Center for Multiple Sclerosis Treatment and Research (L.A.R., A.K.C., D.S.C., J.A.C., A.K.) and Diagnostic Radiology (J.L.), Cleveland Clinic, OH; Department of Neurosciences (J.G.), University of California San Diego, La Jolla, CA; UCSF Weill Institute of Neurosciences (S.S.Z.), University of California at San Francisco; and Department of Neurology (S.D.N.), Johns Hopkins School of Medicine, Baltimore, MD
| | - Jonathan Lee
- From the Mellen Center for Multiple Sclerosis Treatment and Research (L.A.R., A.K.C., D.S.C., J.A.C., A.K.) and Diagnostic Radiology (J.L.), Cleveland Clinic, OH; Department of Neurosciences (J.G.), University of California San Diego, La Jolla, CA; UCSF Weill Institute of Neurosciences (S.S.Z.), University of California at San Francisco; and Department of Neurology (S.D.N.), Johns Hopkins School of Medicine, Baltimore, MD
| | - Alise K Carlson
- From the Mellen Center for Multiple Sclerosis Treatment and Research (L.A.R., A.K.C., D.S.C., J.A.C., A.K.) and Diagnostic Radiology (J.L.), Cleveland Clinic, OH; Department of Neurosciences (J.G.), University of California San Diego, La Jolla, CA; UCSF Weill Institute of Neurosciences (S.S.Z.), University of California at San Francisco; and Department of Neurology (S.D.N.), Johns Hopkins School of Medicine, Baltimore, MD
| | - Devon S Conway
- From the Mellen Center for Multiple Sclerosis Treatment and Research (L.A.R., A.K.C., D.S.C., J.A.C., A.K.) and Diagnostic Radiology (J.L.), Cleveland Clinic, OH; Department of Neurosciences (J.G.), University of California San Diego, La Jolla, CA; UCSF Weill Institute of Neurosciences (S.S.Z.), University of California at San Francisco; and Department of Neurology (S.D.N.), Johns Hopkins School of Medicine, Baltimore, MD
| | - Jeffrey A Cohen
- From the Mellen Center for Multiple Sclerosis Treatment and Research (L.A.R., A.K.C., D.S.C., J.A.C., A.K.) and Diagnostic Radiology (J.L.), Cleveland Clinic, OH; Department of Neurosciences (J.G.), University of California San Diego, La Jolla, CA; UCSF Weill Institute of Neurosciences (S.S.Z.), University of California at San Francisco; and Department of Neurology (S.D.N.), Johns Hopkins School of Medicine, Baltimore, MD
| | - Jennifer Graves
- From the Mellen Center for Multiple Sclerosis Treatment and Research (L.A.R., A.K.C., D.S.C., J.A.C., A.K.) and Diagnostic Radiology (J.L.), Cleveland Clinic, OH; Department of Neurosciences (J.G.), University of California San Diego, La Jolla, CA; UCSF Weill Institute of Neurosciences (S.S.Z.), University of California at San Francisco; and Department of Neurology (S.D.N.), Johns Hopkins School of Medicine, Baltimore, MD
| | - Scott S Zamvil
- From the Mellen Center for Multiple Sclerosis Treatment and Research (L.A.R., A.K.C., D.S.C., J.A.C., A.K.) and Diagnostic Radiology (J.L.), Cleveland Clinic, OH; Department of Neurosciences (J.G.), University of California San Diego, La Jolla, CA; UCSF Weill Institute of Neurosciences (S.S.Z.), University of California at San Francisco; and Department of Neurology (S.D.N.), Johns Hopkins School of Medicine, Baltimore, MD
| | - Scott D Newsome
- From the Mellen Center for Multiple Sclerosis Treatment and Research (L.A.R., A.K.C., D.S.C., J.A.C., A.K.) and Diagnostic Radiology (J.L.), Cleveland Clinic, OH; Department of Neurosciences (J.G.), University of California San Diego, La Jolla, CA; UCSF Weill Institute of Neurosciences (S.S.Z.), University of California at San Francisco; and Department of Neurology (S.D.N.), Johns Hopkins School of Medicine, Baltimore, MD
| | - Amy Kunchok
- From the Mellen Center for Multiple Sclerosis Treatment and Research (L.A.R., A.K.C., D.S.C., J.A.C., A.K.) and Diagnostic Radiology (J.L.), Cleveland Clinic, OH; Department of Neurosciences (J.G.), University of California San Diego, La Jolla, CA; UCSF Weill Institute of Neurosciences (S.S.Z.), University of California at San Francisco; and Department of Neurology (S.D.N.), Johns Hopkins School of Medicine, Baltimore, MD
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Swarup MS, Chandola S, Batra R, Prakash A, Garg A. Radiological approach to non-compressive myelopathies. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2022. [DOI: 10.1186/s43055-022-00736-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Myelopathy, a pathological condition related to the spinal cord can broadly be categorized into compressive and non-compressive aetiologies. Magnetic resonance imaging remains the modality of choice when suspecting non-compressive myelopathy as it helps to localize the affected segment and exclude compression as the cause of myelopathy. This review deals with the imaging approach for non-compressive myelopathies.
Main body
Demyelinating disorders are the most common cause of non-compressive myelopathy and often show confounding features. Other causes include inflammatory, ischemic, metabolic, and neoplastic disorders. Non-compressive myelopathy can broadly be classified into acute and non-acute onset which can further be categorized according to the distribution of the signal abnormalities, including length of cord involvement, specific tract involvement, enhancement pattern, and the region of the spinal cord that is affected.
Conclusions
Imaging plays a critical role in the evaluation of clinically suspected cases of myelopathy and MR imaging (with or without contrast) remains the preferred modality. Compressive causes must be excluded as a cause of myelopathy. Despite a multitude of causes, the most common imaging appearance is a nonspecific T2 hyperintense signal in the spinal cord, and thus, a pragmatic diagnostic approach along with appropriate clinical and biochemical correlation is essential for arriving at an accurate diagnosis.
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Cacciaguerra L, Sechi E, Rocca MA, Filippi M, Pittock SJ, Flanagan EP. Neuroimaging features in inflammatory myelopathies: A review. Front Neurol 2022; 13:993645. [PMID: 36330423 PMCID: PMC9623025 DOI: 10.3389/fneur.2022.993645] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 08/16/2022] [Indexed: 11/15/2022] Open
Abstract
Spinal cord involvement can be observed in the course of immune-mediated disorders. Although multiple sclerosis (MS) represents the leading cause of inflammatory myelopathy, an increasing number of alternative etiologies must be now considered in the diagnostic work-up of patients presenting with myelitis. These include antibody-mediated disorders and cytotoxic T cell-mediated diseases targeting central nervous system (CNS) antigens, and systemic autoimmune conditions with secondary CNS involvement. Even though clinical features are helpful to orient the diagnostic suspicion (e.g., timing and severity of myelopathy symptoms), the differential diagnosis of inflammatory myelopathies is often challenging due to overlapping features. Moreover, noninflammatory etiologies can sometimes mimic an inflammatory process. In this setting, magnetic resonance imaging (MRI) is becoming a fundamental tool for the characterization of spinal cord damage, revealing a pictorial scenario which is wider than the clinical manifestations. The characterization of spinal cord lesions in terms of longitudinal extension, location on axial plane, involvement of the white matter and/or gray matter, and specific patterns of contrast enhancement, often allows a proper differentiation of these diseases. For instance, besides classical features, such as the presence of longitudinally extensive spinal cord lesions in patients with aquaporin-4-IgG positive neuromyelitis optica spectrum disorder (AQP4+NMOSD), novel radiological signs (e.g., H sign, trident sign) have been recently proposed and successfully applied for the differential diagnosis of inflammatory myelopathies. In this review article, we will discuss the radiological features of spinal cord involvement in autoimmune disorders such as MS, AQP4+NMOSD, myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), and other recently characterized immune-mediated diseases. The identification of imaging pitfalls and mimics that can lead to misdiagnosis will also be examined. Since spinal cord damage is a major cause of irreversible clinical disability, the recognition of these radiological aspects will help clinicians achieve a correct and prompt diagnosis, treat early with disease-specific treatment and improve patient outcomes.
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Affiliation(s)
- Laura Cacciaguerra
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Elia Sechi
- Neurology Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Maria A. Rocca
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Filippi
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sean J. Pittock
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Eoin P. Flanagan
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
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Sorrentino S, Ash S, Haupt R, Plantaz D, Schiff I, Hero B, Simon T, Kachanov D, Shamanskaya T, Kraal K, Littooij A, Wieczoreck A, Balwierz W, Laureys G, Trager C, Sertorio F, Erminio G, Fragola M, Beck Popovic M, De Bernardi B, Trahair T. Presenting features of neuroblastoma with spinal canal invasion. A prospective study of the International Society of Pediatric Oncology Europe - Neuroblastoma (SIOPEN). Front Pediatr 2022; 10:1023498. [PMID: 36299690 PMCID: PMC9589152 DOI: 10.3389/fped.2022.1023498] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 09/14/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Between 5 and 15% of children with neuroblastoma (NB) present with or develop spinal canal invasion (SCI). The majority of these children have symptoms of epidural compression of spinal cord and/or spinal nerves. Treatment of NB-SCI is considered an emergency but its modalities are not yet well-established. Independently of treatment, NB-SCI may result in significant long-term disabilities. We report on the first prospective study of NB-SCI focused on presenting characteristics of both symptomatic and asymptomatic patients and correlation between SCI-related symptoms and imaging features. MATERIALS AND METHODS This SIOPEN prospective NB-SCI study opened in June 2014. Patient data including SCI symptoms evaluated by standardized measures and spinal cord imaging studies were collected for each patient. For the purpose of this study data entry was locked on July 2021. RESULTS Of the 208 NB-SCI patients registered, 196 were evaluable for this analysis of whom 67% were symptomatic and 33% asymptomatic. Median age was 11 months. The thorax was the commonest primary tumor site. The median intervals between initial symptoms and diagnosis and between first medical visit and diagnosis were 14 and 3 days, respectively. The was no statistical difference in frequency of presenting characteristics between symptomatic and asymptomatic patients. Presenting features of NB-SCI patients differed from other NBs for older median age, prevalence of thoracic vs. abdominal primary site, prevalence of localized vs. metastatic disease and lower incidence of MYCN gene amplification. The most common SCI features were motor deficit in the younger and pain in the older patients that correlated on imaging with both transverse and longitudinal extent but not with the level of intraspinal tumor. Spinal cord T2-hyperintensity was more frequently detected in symptomatic patients (not significant). CONCLUSION This prospective study confirms that children with NB-SCI differ from NBs without SCI. Compared to previous studies, it provides more detailed information regarding presenting symptoms, time intervals between SCI symptoms, medical visit and diagnosis, and correlations between symptoms and imaging features.
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Affiliation(s)
| | - Shifra Ash
- Joan and Sanford Weill Paediatric Haematology Oncology and Bone Marrow Transplantation Division, Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Riccardo Haupt
- DOPO Clinic, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Dominique Plantaz
- Department de Paediatrics, Hôpital Couple Enfants, CHU Grenoble, Grenoble, France
| | - Isabelle Schiff
- Department de Paediatrics, Hôpital Couple Enfants, CHU Grenoble, Grenoble, France
| | - Barbara Hero
- Department of Paediatric Haematology and Oncology, Children's Hospital, University of Cologne, Cologne, Germany
| | - Thorsten Simon
- Department of Paediatric Haematology and Oncology, Children's Hospital, University of Cologne, Cologne, Germany
| | - Denis Kachanov
- Department of Clinical Oncology, Dmitry Rogachev National Medical Research Center of Paediatric Haematology, Oncology and Immunology, Moscow, Russia
| | - Tatyana Shamanskaya
- Department of Clinical Oncology, Dmitry Rogachev National Medical Research Center of Paediatric Haematology, Oncology and Immunology, Moscow, Russia
| | - Katheljine Kraal
- Princess Màxima Centre for Paediatric Oncology, Utrecht, Netherlands
| | | | - Alexsandra Wieczoreck
- Paediatric Oncology and Haematology Department, Institute of Paediatrics, Jagiellonian University, Krakow, Poland
| | - Walentyna Balwierz
- Paediatric Oncology and Haematology Department, Institute of Paediatrics, Jagiellonian University, Krakow, Poland
| | - Geneviève Laureys
- Department of Paediatric Haematology-Oncology, Prinses Elisabeth Kinderziekenhuis, University Hospital, Gent, Belgium
| | - Catherine Trager
- Women's and Childrens Health, Karolinska Institutet, Stockholm, Sweden
| | | | - Giovanni Erminio
- Scientific Directorate, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Martina Fragola
- Scientific Directorate, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Maja Beck Popovic
- Centre Hospitalier Universitaire Vaudois, Unité d'Hémato-Oncologie Pédiatrique, Lausanne, Switzerland
| | - Bruno De Bernardi
- Paediatric Oncology Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Toby Trahair
- Kids Cancer Center, Sydney Children's Hospital, Randwick, NSW, Australia.,Children's Cancer Institute, Lowy Cancer Research Centre, University of New South Wales, Kensington, NSW, Australia.,School of Women's and Children's Health, University of New South Wales, Kensington, NSW, Australia
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Herrera Herrera I, Garrido Morro I, Guzmán de Villoria Lebiedziejewski J, Ordoñez González C, Rovira À. Enfoque clínico-radiológico de la mielopatía no traumática. RADIOLOGIA 2020; 62:464-480. [DOI: 10.1016/j.rx.2020.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/28/2020] [Accepted: 07/02/2020] [Indexed: 11/16/2022]
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Herrera Herrera I, Garrido Morro I, Guzmán de Villoria Lebiedziejewski J, Ordoñez González C, Rovira À. Clinical-radiological approach to nontraumatic myelopathy. RADIOLOGIA 2020. [DOI: 10.1016/j.rxeng.2020.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Lee MJ, Aronberg R, Manganaro MS, Ibrahim M, Parmar HA. Diagnostic Approach to Intrinsic Abnormality of Spinal Cord Signal Intensity. Radiographics 2020; 39:1824-1839. [PMID: 31589577 DOI: 10.1148/rg.2019190021] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Intramedullary cord hyperintensity at T2-weighted MRI is a common imaging feature of disease in the spinal cord, but it is nonspecific. Radiologists play a valuable role in helping narrow the differential diagnosis by integrating patient history and laboratory test results with key imaging characteristics. The authors present an algorithmic approach to evaluating intrinsic abnormality of spinal cord signal intensity (SI), which incorporates clinical evaluation results, time of onset (acute vs nonacute), cord expansion, and pattern of T2 SI abnormality. This diagnostic approach provides a practical framework to aid both trainees and practicing radiologists in workup of myelopathy.©RSNA, 2019.
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Affiliation(s)
- Michael J Lee
- From the Department of Radiology, Division of Neuroradiology, University of Michigan Health System, 1500 E Medical Center Dr, UH B1-D502, Ann Arbor, MI 48109
| | - Ryan Aronberg
- From the Department of Radiology, Division of Neuroradiology, University of Michigan Health System, 1500 E Medical Center Dr, UH B1-D502, Ann Arbor, MI 48109
| | - Matthew S Manganaro
- From the Department of Radiology, Division of Neuroradiology, University of Michigan Health System, 1500 E Medical Center Dr, UH B1-D502, Ann Arbor, MI 48109
| | - Mohannad Ibrahim
- From the Department of Radiology, Division of Neuroradiology, University of Michigan Health System, 1500 E Medical Center Dr, UH B1-D502, Ann Arbor, MI 48109
| | - Hemant A Parmar
- From the Department of Radiology, Division of Neuroradiology, University of Michigan Health System, 1500 E Medical Center Dr, UH B1-D502, Ann Arbor, MI 48109
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Klein JP. Imaging of noninfectious inflammatory disorders of the spinal cord. HANDBOOK OF CLINICAL NEUROLOGY 2017; 136:733-46. [PMID: 27430439 DOI: 10.1016/b978-0-444-53486-6.00036-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Myelitis, or inflammation of the spinal cord, produces a characteristic clinical syndrome. Among the many causes of myelitis are the prototypical demyelinating diseases multiple sclerosis and neuromyelitis optica, each of which has distinct clinical, pathologic, and radiographic features. Less distinct are the myelitides associated with systemic autoimmune conditions like sarcoidosis and lupus. Nondemyelinating conditions such as arachnoiditis, dural arteriovenous fistula, and tumor infiltration may also produce inflammation of the spinal cord. The objective of this review is to aid the clinician in the radiographic diagnosis of noninfectious inflammatory diseases of the spinal cord.
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Affiliation(s)
- Joshua P Klein
- Departments of Neurology and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
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Evaluation and management of longitudinally extensive transverse myelitis: a guide for radiologists. Clin Radiol 2016; 71:960-971. [DOI: 10.1016/j.crad.2016.05.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 04/22/2016] [Accepted: 05/23/2016] [Indexed: 01/31/2023]
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Palasis S, Hayes LL. Acquired pathology of the pediatric spine and spinal cord. Pediatr Radiol 2015; 45 Suppl 3:S420-32. [PMID: 26346148 DOI: 10.1007/s00247-015-3328-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2014] [Revised: 12/21/2014] [Accepted: 02/24/2015] [Indexed: 12/13/2022]
Abstract
Pediatric spine pathology poses a diagnostic challenge for radiologists. Acquired spine pathology often yields nonspecific signs and symptoms in children, especially in the younger age groups, and diagnostic delay can carry significant morbidity. This review is focused on some of the more common diagnostic dilemmas we face when attempting to evaluate and diagnose acquired pediatric spine anomalies in daily practice. An understanding of some of the key differentiating features of these disease processes in conjunction with pertinent history, physical exam, and advanced imaging techniques can indicate the correct diagnosis.
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Affiliation(s)
- Susan Palasis
- Department of Radiology at Scottish Rite, Children's Healthcare of Atlanta, 1001 Johnson Ferry Road, Atlanta, GA, 30342, USA,
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