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Kim JA, Jang H, Choi Y, Min YG, Hong YH, Sung JJ, Choi SJ. Subclinical articulatory changes of vowel parameters in Korean amyotrophic lateral sclerosis patients with perceptually normal voices. PLoS One 2023; 18:e0292460. [PMID: 37831677 PMCID: PMC10575489 DOI: 10.1371/journal.pone.0292460] [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: 04/18/2023] [Accepted: 09/21/2023] [Indexed: 10/15/2023] Open
Abstract
The available quantitative methods for evaluating bulbar dysfunction in patients with amyotrophic lateral sclerosis (ALS) are limited. We aimed to characterize vowel properties in Korean ALS patients, investigate associations between vowel parameters and clinical features of ALS, and analyze subclinical articulatory changes of vowel parameters in those with perceptually normal voices. Forty-three patients with ALS (27 with dysarthria and 16 without dysarthria) and 20 healthy controls were prospectively collected in the study. Dysarthria was assessed using the ALS Functional Rating Scale-Revised (ALSFRS-R) speech subscores, with any loss of 4 points indicating the presence of dysarthria. The structured speech samples were recorded and analyzed using Praat software. For three corner vowels (/a/, /i/, and /u/), data on the vowel duration, fundamental frequency, frequencies of the first two formants (F1 and F2), harmonics-to-noise ratio, vowel space area (VSA), and vowel articulation index (VAI) were extracted from the speech samples. Corner vowel durations were significantly longer in ALS patients with dysarthria than in healthy controls. The F1 frequency of /a/, F2 frequencies of /i/ and /u/, the VSA, and the VAI showed significant differences between ALS patients with dysarthria and healthy controls. The area under the curve (AUC) was 0.912. The F1 frequency of /a/ and the VSA were the major determinants for differentiating ALS patients who had not yet developed apparent dysarthria from healthy controls (AUC 0.887). In linear regression analyses, as the ALSFRS-R speech subscore decreased, both the VSA and VAI were reduced. In contrast, vowel durations were found to be rather prolonged. The analyses of vowel parameters provided a useful metric correlated with disease severity for detecting subclinical bulbar dysfunction in ALS patients.
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Affiliation(s)
- Jin-Ah Kim
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Translational Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Genomic Medicine Institute, Medical Research Center, Seoul National University, Seoul, Republic of Korea
| | - Hayeun Jang
- Division of English, Busan University of Foreign Studies, Busan, Republic of Korea
| | - Yoonji Choi
- Department of Korean Language and Literature, Seoul National University, Seoul, Republic of Korea
| | - Young Gi Min
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Translational Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yoon-Ho Hong
- Department of Neurology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Jung-Joon Sung
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
- Neuroscience Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seok-Jin Choi
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
- Center for Hospital Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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Split-elbow sign in the PRO-ACT and Southern Italy ALS cohorts: a potential marker of disease severity and lower motor neuron involvement? J Neurol 2023; 270:3204-3212. [PMID: 36917342 DOI: 10.1007/s00415-023-11660-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/01/2023] [Accepted: 03/02/2023] [Indexed: 03/16/2023]
Abstract
INTRODUCTION Split phenomena in ALS refers to the preferential dysfunction of some groups of muscles over others. The split-elbow sign (SE) is characterized by the predominant weakness of the biceps compared to the triceps, but available results are conflicting. OBJECTIVES To evaluate the prevalence of the SE in two independent cohorts: the randomized controlled trial-based PRO-ACT cohort (n = 500) and a monocentric cohort of patients with ALS from Southern Italy (n = 144); to investigate the demographic and clinical variables associated with the SE sign. METHODS Wilcoxon signed-rank test was used to compare biceps with triceps power in the same limb measured by hand-held dynamometry in the PRO-ACT cohort and Medical Research Council (MRC) in our cohort. Each limb was considered independently and not paired within the same individual. The arm where the triceps was stronger than the biceps was defined SE + , whereas the arm where the biceps was stronger than the triceps was considered SE-. A backward stepwise multivariate logistic regression was used to analyze the relationship between clinical and demographic variables and SE. PENN Upper Motor Neuron and Devine scales were used to evaluate the different upper (UMN) and lower (LMN) motor neuron impairments between the SE + and SE- arms. RESULTS In both cohorts, the biceps were on average stronger than the triceps, and the SE sign was present in 41% of the PRO-ACT cohort and just 30% of the Southern Italy cohort. The multivariate logistic regression revealed that older age (OR: 1.45; p = 0.01), male gender (OR: 1.55; p = 0.002), spinal onset (OR: 1.59; p = 0.007), and higher disease severity (OR: 1.70; p = 0.001) were significant predictors of the SE sign in the PRO-ACT cohort. Conversely, in Southern Italy patients, only a lower ALSFRS-R score was a significant determinant of the SE (OR: 8.47; p = 0.008). Finally, SE + arms exhibited a significantly higher median Devine sub-score compared to SE- [1 vs 0, p = < 0.05], while arms SE- showed a significantly higher median PUMNS sub-score [2 vs 0; p = < 0.05)]. CONCLUSION In our study, most patients with ALS do not show SE. Patients with SE are more likely older, males, with spinal onset, a higher degree of disease severity, and predominant and wider LMN impairment.
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Pavey N, Higashihara M, van den Bos MA, Menon P, Vucic S. The split-elbow index: A biomarker of the split elbow sign in ALS. Clin Neurophysiol Pract 2021; 7:16-20. [PMID: 35024511 PMCID: PMC8733259 DOI: 10.1016/j.cnp.2021.11.002] [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: 07/26/2021] [Revised: 11/03/2021] [Accepted: 11/16/2021] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVE The split elbow sign is a clinical feature of amyotrophic lateral sclerosis (ALS), characterised by preferential weakness of biceps brachii muscle compared to triceps. A novel neurophysiological index, termed the split elbow index (SEI), was developed to quantify the split-elbow sign, and assess its utility in ALS. METHODS Clinical and neurophysiological assessment was prospectively undertaken on 34 ALS patients and 32 ALS mimics. Compound muscle action potential (CMAP) amplitude was recorded from biceps brachii and triceps muscles from which the SEI was calculated using the following formula: SEI = CMAPamplitudeBICEPSBRACHII CMAPamplitudeTRICEPSBRACHII . RESULTS The split elbow sign was significantly more common in ALS patients when compared to ALS mimic patients (P < 0.05). The SEI was significantly reduced in ALS patients when compared to ALS mimics (P < 0.01). This reduction was evident in spinal and bulbar onset ALS. A SEI cut-off value of ≤0.62 exhibited a sensitivity of 71% and specificity of 61%. CONCLUSIONS The split elbow sign is significantly more common in ALS patients, and was supported by a reduction in the SEI. SIGNIFICANCE The SEI may be utilised as a surrogate biomarker of the split elbow sign in future ALS studies.
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Affiliation(s)
- Nathan Pavey
- Brain and Nerve Research Center, Concord Clinical School, University of Sydney, Sydney, Australia
| | - Mana Higashihara
- Department of Neurology, Tokyo Metropolitan Geriatric Hospital, Tokyo, Japan
| | - Mehdi A.J. van den Bos
- Brain and Nerve Research Center, Concord Clinical School, University of Sydney, Sydney, Australia
| | - Parvathi Menon
- Brain and Nerve Research Center, Concord Clinical School, University of Sydney, Sydney, Australia
- Department of Neurology, Tokyo Metropolitan Geriatric Hospital, Tokyo, Japan
| | - Steve Vucic
- Brain and Nerve Research Center, Concord Clinical School, University of Sydney, Sydney, Australia
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Eisen A, Bede P. The strength of corticomotoneuronal drive underlies ALS split phenotypes and reflects early upper motor neuron dysfunction. Brain Behav 2021; 11:e2403. [PMID: 34710283 PMCID: PMC8671797 DOI: 10.1002/brb3.2403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 09/02/2021] [Accepted: 10/05/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Split phenotypes, (split hand, elbow, leg, and foot), are probably unique to ALS, and are characterized by having a shared peripheral input of both affected and unaffected muscles. This implies an anatomical origin rostral to the spinal cord, primarily within the cerebral cortex. Therefore, split phenotypes are a potential marker of ALS upper motor neuron pathology. However, to date, reports documenting upper motor neuron dysfunction in split phenotypes have been limited to using transcranial magnetic stimulation and cortical threshold tracking techniques. Here, we consider several other potential methodologies that could confirm a primary upper motor neuron pathology in split phenotypes. METHODS We review the potential of: 1. measuring the compound excitatory post-synaptic potential recorded from a single activated motor unit, 2. cortical-muscular coherence, and 3. new advanced modalities of neuroimaging (high-resolution imaging protocols, ultra-high field MRI platforms [7T], and novel Non-Gaussian diffusion models). CONCLUSIONS We propose that muscles involved in split phenotypes are those functionally involved in the human motor repertoire used particularly in complex activities. Their anterior horn cells receive the strongest corticomotoneuronal input. This is also true of the weakest muscles that are the earliest to be affected in ALS. Descriptions of split hand in non-ALS cases and proposals that peripheral nerve or muscle dysfunction may be causative are contentious. Only a few carefully controlled cases of each form of split phenotype, using upper motor neuron directed methodologies, are necessary to prove our postulate.
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Affiliation(s)
- Andrew Eisen
- Division of Neurology, Department of Medicine, University of British Columbia, British Columbia, Canada
| | - Peter Bede
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland.,Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France
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Corcia P, Bede P, Pradat PF, Couratier P, Vucic S, de Carvalho M. Split-hand and split-limb phenomena in amyotrophic lateral sclerosis: pathophysiology, electrophysiology and clinical manifestations. J Neurol Neurosurg Psychiatry 2021; 92:1126-1130. [PMID: 34285065 DOI: 10.1136/jnnp-2021-326266] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 07/05/2021] [Indexed: 11/03/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disorder affecting the upper and lower motor neurons. A key clinical feature of ALS is the absence of accurate, early-stage diagnostic indicators. 'Split-hand syndrome' was first described in ALS at the end of the last century and a considerable body of literature suggests that the split-hand phenomenon may be an important clinical feature of ALS. Considering the published investigations, it is conceivable that the 'split-hand syndrome' results from the associated upper and lower motor neuron degeneration, whose interaction remains to be fully clarified. Additionally, other split syndromes have been described in ALS involving upper or lower limbs, with a nuanced description of clinical and neurophysiological manifestations that may further aid ALS diagnosis. In this review, we endeavour to systematically present the spectrum of the 'split syndromes' in ALS from a clinical and neurophysiology perspective and discuss their diagnostic and pathogenic utility.
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Affiliation(s)
- Philippe Corcia
- Centre Constitutif de Référence SLA, CHU Bretonneau, Tours, France
| | - Peter Bede
- Computational Neuroimaging Group, Trinity College Dublin, Ireland.,Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France
| | - Pierre-François Pradat
- Neurology, Hopital Pitie-Salpetriere, Paris, France.,LIB, Université Pierre et Marie Curie Faculté de Médecine, Paris, Île-de-France, France
| | | | - Steve Vucic
- Westmead Clinical School, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia.,Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Mamede de Carvalho
- Instituto de Fisiologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisbon, Lisbon, Portugal.,Department of Neurosciences and Mental Health, Hospital de Santa Maria, Lisboa, Portugal
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Thakore NJ, Drawert BJ, Lapin BR, Pioro EP. Progressive arm muscle weakness in ALS follows the same sequence regardless of onset site: use of TOMS, a novel analytic method to track limb strength. Amyotroph Lateral Scler Frontotemporal Degener 2021; 22:380-387. [PMID: 33620270 PMCID: PMC8292176 DOI: 10.1080/21678421.2021.1889000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 12/29/2020] [Accepted: 02/07/2021] [Indexed: 10/22/2022]
Abstract
Objective: Examine sequence of weakness in arm muscles from longitudinal hand-held dynamometry (HHD) data in ALS for congruence with contiguous spread of neurodegeneration along spinal cord segments. Methods: Longitudinal HHD data from the Ceftriaxone clinical trial were examined using nonlinear mixed models, assuming a logistic trajectory from normal to zero strength. Unobserved baseline normal strength of weak muscles was assumed using strength of the best-preserved muscle. A novel metric called "time from onset to midway strength" (TOMS) was estimated for each muscle group, and TOMS ratios were examined to identify sequence of weakness, overall and by onset site. Results: Shoulder flexion (SF), elbow flexion (EF), elbow extension (EE), wrist extension (WE), and first dorsal interosseous (FDI) were measured on each side. Over a median of 36 weeks, 513 subjects provided 2589 sets of HHD measures. TOMS increased sequentially in the following order: FDI, WE, SF, EF, and EE. TOMS ratios estimates with 95% CIs (adjusted for multiple comparisons) were: WE/FDI 1.32 (1.24-1.41), SF/WE 1.06 (1.01-1.10), EF/SF 1.06 (1.02-1.10), and EE/EF 1.18 (1.12-1.23). Elbow and shoulder flexors weakened sooner than did elbow extensors. The sequence of arm muscle weakness progression was similar regardless of onset site. Conclusion: Nonsegmental progression of arm muscle weakness that is similar for different onset sites favors cortical influence/network spread over contiguous spread of neurodegeneration in the spinal cord. Furthermore, this study confirms the "split elbow" pattern. TOMS and other proposed methods may have value as outcome measures in clinical research.
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Affiliation(s)
- Nimish J. Thakore
- Department of Neurology, Neuromuscular Center, Cleveland Clinic, Cleveland, OH, USA
| | - Brian J. Drawert
- Department of Computer Science, University of North Carolina at Asheville, Asheville, NC, USA
| | - Brittany R. Lapin
- Quantitative Health Sciences/Neurological Institute Center for Outcomes Research and Evaluation (NICORE), Cleveland Clinic, Cleveland, OH, USA
| | - Erik P. Pioro
- Department of Neurology, Neuromuscular Center, Cleveland Clinic, Cleveland, OH, USA
- Department of Neurosciences, Lerner Research Institute, Cleveland Clinic, OH, USA
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Eisen A. The Dying Forward Hypothesis of ALS: Tracing Its History. Brain Sci 2021; 11:brainsci11030300. [PMID: 33673524 PMCID: PMC7997258 DOI: 10.3390/brainsci11030300] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 02/25/2021] [Indexed: 01/15/2023] Open
Abstract
The site of origin of amyotrophic lateral sclerosis (ALS), although unsettled, is increasingly recognized as being cortico-fugal, which is a dying-forward process primarily starting in the corticomotoneuronal system. A variety of iterations of this concept date back to over 150 years. Recently, the hallmark TAR DNA-binding protein 43 (TDP-43) pathology, seen in >95% of patients with ALS, has been shown to be largely restricted to corticofugal projecting neurons (“dying forward”). Possibly, soluble but toxic cytoplasmic TDP-43 could enter the axoplasm of Betz cells, subsequently causing dysregulation of nuclear protein in the lower brainstem and spinal cord anterior horn cells. As the disease progresses, cortical involvement in ALS becomes widespread, including or starting with frontotemporal dementia, implying a broader view of ALS as a brain disease. The onset at the motor and premotor cortices should be considered a nidus at the edge of multiple cortical networks which eventually become disrupted, causing failure of a widespread cortical connectome.
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Affiliation(s)
- Andrew Eisen
- Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC V5Z 1M9, Canada
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Ludolph AC, Emilian S, Dreyhaupt J, Rosenbohm A, Kraskov A, Lemon RN, Del Tredici K, Braak H. Pattern of paresis in ALS is consistent with the physiology of the corticomotoneuronal projections to different muscle groups. J Neurol Neurosurg Psychiatry 2020; 91:991-998. [PMID: 32665323 DOI: 10.1136/jnnp-2020-323331] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/14/2020] [Accepted: 05/15/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE A recent neuroanatomical staging scheme of amyotrophic lateral sclerosis (ALS) indicates that a cortical lesion may spread, as a network disorder, both at the cortical level and via corticofugal tracts, including corticospinal projections providing direct monosynaptic input to α-motoneurons. These projections are involved preferentially and early in ALS. If these findings are clinically relevant, the pattern of paresis in ALS should primarily involve those muscle groups that receive the strongest direct corticomotoneuronal (CM) innervation. METHODS In a large cohort (N=436), we analysed retrospectively the pattern of muscle paresis in patients with ALS using the UK Medical Research Council (MRC) scoring system; we subsequently carried out two independent prospective studies in two smaller groups (N=92 and N=54). RESULTS The results indicated that a characteristic pattern of paresis exists. When pairs of muscle groups were compared within patients, the group known to receive the more pronounced CM connections was significantly weaker. Within patients, there was greater relative weakness (lower MRC score) in thumb abductors versus elbow extensors, for hand extensors versus hand flexors and for elbow flexors versus elbow extensors. In the lower limb, knee flexors were relatively weaker than extensors, and plantar extensors were weaker than plantar flexors. CONCLUSIONS These findings were mostly significant (p<0.01) for all six pairs of muscles tested and provide indirect support for the concept that ALS may specifically affect muscle groups with strong CM connections. This specific pattern could help to refine clinical and electrophysiological ALS diagnostic criteria and complement prospective clinicopathological correlation studies.
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Affiliation(s)
- Albert C Ludolph
- Department of Neurology, University of Ulm, 89081 Ulm, Germany .,German Center for Neurodegenerative Diseases (DZNE), Ulm, Germany
| | - Susanne Emilian
- Department of Neurology, University of Ulm, 89081 Ulm, Germany
| | - Jens Dreyhaupt
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | | | - Alexander Kraskov
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK
| | - Roger N Lemon
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, Queen Square, London, UK
| | - Kelly Del Tredici
- Department of Neurology, Clinical Neuroanatomy (Center for Biomedical Research), Ulm, Germany
| | - Heiko Braak
- Department of Neurology, Clinical Neuroanatomy (Center for Biomedical Research), Ulm, Germany
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Pathophysiology and Diagnosis of ALS: Insights from Advances in Neurophysiological Techniques. Int J Mol Sci 2019; 20:ijms20112818. [PMID: 31185581 PMCID: PMC6600525 DOI: 10.3390/ijms20112818] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 05/27/2019] [Accepted: 06/06/2019] [Indexed: 12/28/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a rapidly progressive and fatal neurodegenerative disorder of the motor neurons, characterized by focal onset of muscle weakness and incessant disease progression. While the presence of concomitant upper and lower motor neuron signs has been recognized as a pathognomonic feature of ALS, the pathogenic importance of upper motor neuron dysfunction has only been recently described. Specifically, transcranial magnetic stimulation (TMS) techniques have established cortical hyperexcitability as an important pathogenic mechanism in ALS, correlating with neurodegeneration and disease spread. Separately, ALS exhibits a heterogeneous clinical phenotype that may lead to misdiagnosis, particularly in the early stages of the disease process. Cortical hyperexcitability was shown to be a robust diagnostic biomarker if ALS, reliably differentiating ALS from neuromuscular mimicking disorders. The present review will provide an overview of key advances in the understanding of ALS pathophysiology and diagnosis, focusing on the importance of cortical hyperexcitability and its relationship to advances in genetic and molecular processes implicated in ALS pathogenesis.
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