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Fujimoto K, Hisanaga S, Kuroda S, Kodama K, Sugiyama F, Kikuchi M, Kita T, Yamashita A, Nagai T, Kamimura T, Kaikita K, Imamura T, Fujimoto S. A case of primary aldosteronism with excessive secretion of renin that was unmasked by kidney transplantation. CEN Case Rep 2024; 13:1-8. [PMID: 37010722 PMCID: PMC10834915 DOI: 10.1007/s13730-023-00784-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 03/10/2023] [Indexed: 04/04/2023] Open
Abstract
A 42-year-old man showed marked hypokalemia after kidney transplantation. He was diagnosed with hypertension and suffered from acute myocardial infarction at 33 and 38 years of age. At 40 years of age, hemodialysis was introduced. A left adrenal tumor was noted and suspected as a non-functional adrenal adenoma at that time. Therefore, he received a living-donor kidney transplant at 42 years of age. After kidney transplantation, the serum creatinine level dropped. His blood pressure remained high, and the serum potassium level decreased. The PRA and PAC were elevated, and ARR was not elevated. Based on the results of various confirmatory tests and vein sampling, he was diagnosed with excessive secretion of renin from the native kidneys that was complicated by primary aldosteronism (PA), and left nephrectomy and adrenalectomy were performed. The overproduction of aldosterone in the resected adrenal adenoma and over secretion of renin in the kidney with arteriolosclerosis were immunohistologically confirmed. After surgery, the PAC decreased, but the PRA did not decrease. The postoperative serum potassium level improved, and the blood pressure was well controlled with a small dose of medication. This is the first reported case of PA with hyperreninemia after kidney transplantation. It should be noted that PA in dialysis patients and kidney transplant recipients may not fulfill the usual diagnostic criteria of an elevated ARR. In such patients, PA should be suspected based on the absolute value of the PAC and responsiveness to ACTH stimulation, and adrenal and renal vein sampling is required for a definitive diagnosis.
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Affiliation(s)
- Kenta Fujimoto
- Department of Internal Medicine, Koga General Hospital, Miyazaki, Japan, 1749-1 Sudaki, Ikeuchi, 880-0041.
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan.
| | - Shuichi Hisanaga
- Department of Internal Medicine, Koga General Hospital, Miyazaki, Japan, 1749-1 Sudaki, Ikeuchi, 880-0041
| | - Sayaka Kuroda
- Department of Internal Medicine, Koga General Hospital, Miyazaki, Japan, 1749-1 Sudaki, Ikeuchi, 880-0041
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Kotoko Kodama
- Department of Internal Medicine, Koga General Hospital, Miyazaki, Japan, 1749-1 Sudaki, Ikeuchi, 880-0041
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Fumiko Sugiyama
- Department of Internal Medicine, Koga General Hospital, Miyazaki, Japan, 1749-1 Sudaki, Ikeuchi, 880-0041
| | - Masao Kikuchi
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Toshihiro Kita
- Department of Projects Research, Frontier Science Research Center, University of Miyazaki, Miyazaki, Japan
| | - Atsushi Yamashita
- Pathophysiology Section, Department of Pathology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Takahiro Nagai
- Department of Urology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Toshio Kamimura
- Department of Urology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Koichi Kaikita
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Takuroh Imamura
- Department of Internal Medicine, Koga General Hospital, Miyazaki, Japan, 1749-1 Sudaki, Ikeuchi, 880-0041
| | - Shouichi Fujimoto
- Department of Hemovascular Medicine and Artificial Organs, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
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Wada N, Baba S, Sugawara H, Miyoshi A, Obara S. Prolonged postoperative hypoaldosteronism related to hyperkalemia in patients with aldosterone-producing adenoma. Endocr J 2023; 70:917-924. [PMID: 37423737 DOI: 10.1507/endocrj.ej23-0174] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/11/2023] Open
Abstract
Hyperkalemia is developed in a part of patients with aldosterone-producing adenoma (APA) after adrenalectomy, suspected to be due to the insufficiency of aldosterone secretion. The purpose of this study is to determine the frequency and characteristics of prolonged postoperative hypoaldosteronism (PPHA) using chemiluminescent enzyme immunoassay (CLEIA). We studied 58 patients with APA with long time after adrenalectomy and whose PAC was measured using a CLEIA kit. The PAC value measured using CLEIA was significantly lower than that of using RIA between two consecutive visits before and after the shift of measuring method of PAC (median [interquantile range], 123.0 [99.8-164.0] vs. 39.5 [15.8-64.2] pg/mL, p < 0.01). PAC was below the minimum limit of quantification (4.0 pg/mL) of the CLEIA kit at least once in nine patients (15.5%) who had PPHA. The PPHA group were older (mean ± standard deviation, 61.3 ± 8.5 vs. 50.5 ± 10.1 years, p < 0.01) and had lower eGFR (60.3 ± 14.0 vs. 82.3 ± 22.8 mL/min/1.73 m2, p < 0.01) than the non-PPHA group. The frequency of postoperative hyperkalemia (maximum serum potassium >5.5 mEq/L) was higher in the PPHA group than in the non-PPHA group (55.6% vs. 8.2%, p < 0.01). In conclusion, a few patients with APA long time after adrenalectomy had unmeasurable PAC using CLEIA. PPHA is likely to develop in patients with APA after adrenalectomy who are older and have impaired renal function. Additionally, PPHA is related to the occurrence of postoperative hyperkalemia.
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Affiliation(s)
- Norio Wada
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo 060-8604, Japan
| | - Shuhei Baba
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo 060-8604, Japan
| | - Hajime Sugawara
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo 060-8604, Japan
| | - Arina Miyoshi
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo 060-8604, Japan
| | - Shinji Obara
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo 060-8604, Japan
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Carsote M. The Entity of Connshing Syndrome: Primary Aldosteronism with Autonomous Cortisol Secretion. Diagnostics (Basel) 2022; 12:diagnostics12112772. [PMID: 36428832 PMCID: PMC9689802 DOI: 10.3390/diagnostics12112772] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/22/2022] [Accepted: 11/08/2022] [Indexed: 11/15/2022] Open
Abstract
Connshing syndrome (CoSh) (adrenal-related synchronous aldosterone (A) and cortisol (C) excess) represents a distinct entity among PA (primary hyperaldosteronisms) named by W. Arlt et al. in 2017, but the condition has been studied for more than 4 decades. Within the last few years, this is one of the most dynamic topics in hormonally active adrenal lesions due to massive advances in steroids metabolomics, molecular genetics from CYP11B1/B2 immunostaining to genes constellations, as well as newly designated pathological categories according to the 2022 WHO classification. In gross, PA causes 4-10% of all high blood pressure (HBP) cases, and 20% of resistant HBP; subclinical Cushing syndrome (SCS) is identified in one-third of adrenal incidentalomas (AI), while CoSh accounts for 20-30% to 77% of PA subjects, depending on the tests used to confirm autonomous C secretion (ACS). The clinical picture overlaps with PA, hypercortisolemia being mild. ACS is suspected in PA if a more severe glucose and cardiovascular profile is identified, or there are larger tumours, ACS being an independent factor risk for kidney damage, and probably also for depression/anxiety and osteoporotic fractures. It seems that one-third of the PA-ACS group harbours mutations of C-related lines like PRKACA and GNAS. A novel approach means we should perform CYP11B2/CYP11B1 immunostaining; sometimes negative aldosteronoma for CYP11B1 is surrounded by micronodules or cell clusters with positive CYP11B1 to sustain the C excess. Pitfalls of hormonal assessments in CoSh include the index of suspicion (check for ACS in PA patients) and the interpretation of A/C ratio during adrenal venous sample. Laparoscopic adrenalectomy is the treatment of choice. Post-operative clinical remission rate is lower in CoSh than PA. The risk of clinically manifested adrenal insufficiency is low, but a synthetic ACTH stimulating testing might help to avoid unnecessary exposure to glucocorticoids therapy. Finally, postponing the choice of surgery may impair the outcome, having noted that long-term therapy with mineralocorticoids receptors antagonists might not act against excessive amounts of C. Awareness of CoSh improves management and overall prognosis.
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Affiliation(s)
- Mara Carsote
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy & C.I. Parhon National Institute of Endocrinology, 011683 Bucharest, Romania
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Becker LS, Hinrichs MH, Werncke T, Dewald CLA, Maschke SK, Limbourg FP, Ringe KI, Hinrichs JB, Wacker F, Meyer BC. Adrenal venous sampling in primary hyperaldosteronism: correlation of hormone indices and collimated C-arm CT findings. Abdom Radiol (NY) 2021; 46:3471-3481. [PMID: 33674958 PMCID: PMC8215038 DOI: 10.1007/s00261-021-03003-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/10/2021] [Accepted: 02/13/2021] [Indexed: 01/08/2023]
Abstract
PURPOSE To evaluate the feasibility and effect of an approach to adrenal venous sampling (AVS) analysis by combining established selective cortisol and aldosterone indices with the acquisition of a collimated C-arm CT(CACTColl). METHODS Overall, 107 consecutive patients (45f,62 m; 54 ± 10 years) undergoing 111 AVS procedures without hormonal stimulation from 7/13 to 2/20 in a single institution were retrospectively analysed. Hormone levels were measured in sequential samples of the suspected adrenal veins and right iliac vein, and selectivity indices (SI) computed. Stand-alone SICortisol and/or SIAldosterone ≥ 2.0 as well as SICortisol and/or SIAldosterone ≥ 1.1 combined with positive right-sided CACTColl of the adrenals (n = 80; opacified right adrenal vein) were defined as a successful AVS procedure. Radiation exposure of CACT was measured via dose area product (DAP) and weighed against an age-/weight-matched cohort (n = 66). RESULTS Preliminary success rates (SICortisol and/or SIAldosterone ≥ 2.0) were 99.1% (left) and 72.1% (right). These could be significantly increased to a 90.1% success rate on the right, by combining an adjusted SI of 1.1 with a positive CACTColl proving the correct sampling position. Sensitivity for stand-alone collimated CACT (CACTColl) was 0.93, with 74/80 acquired CACTColl confirming selective cannulation by adrenal vein enhancement. Mean DAPColl_CACT measured 2414 ± 958 μGyxm2, while mean DAPFull-FOV_CACT in the matched cohort measured 8766 ± 1956 μGyxm2 (p < 0.001). CONCLUSION Collimated CACT in AVS procedures is feasible and leads to a significant increase in success rates of (right-sided) selective cannulation and may in combination with adapted hormone indices, offer a successful alternative to previously published AVS analysis algorithms with lower radiation exposure compared to a full-FOV CACT.
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Affiliation(s)
- L S Becker
- Department of Diagnostic and Interventional Radiology, Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - M H Hinrichs
- Department of Diagnostic and Interventional Radiology, Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - T Werncke
- Department of Diagnostic and Interventional Radiology, Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - C L A Dewald
- Department of Diagnostic and Interventional Radiology, Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - S K Maschke
- Department of Diagnostic and Interventional Radiology, Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - F P Limbourg
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - K I Ringe
- Department of Diagnostic and Interventional Radiology, Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - J B Hinrichs
- Department of Diagnostic and Interventional Radiology, Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - F Wacker
- Department of Diagnostic and Interventional Radiology, Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - B C Meyer
- Department of Diagnostic and Interventional Radiology, Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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Vermue FC, van den Berg SAA. Validation of the Fujirebio Lumipulse G1200 aldosterone assay for measurements during adrenal venous sampling for primary hyperaldosteronism. Clin Chem Lab Med 2021; 59:e442-e444. [PMID: 33827152 DOI: 10.1515/cclm-2021-0102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/26/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Febe C Vermue
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Sjoerd A A van den Berg
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands.,Department of Clinical Chemistry, Erasmus Medical Center, Rotterdam, The Netherlands
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Wada N, Miyoshi A, Usubuchi H, Terae S, Shibayama Y, Takahashi B, Baba S, Sugawara H, Obara S. Prediction of unilateral hyperaldosteronism on adrenal vein sampling using captopril challenge test in patients with primary aldosteronism. Endocr J 2021; 68:45-51. [PMID: 32848105 DOI: 10.1507/endocrj.ej20-0329] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Captopril challenge test (CCT) is a simple and safe confirmatory test for primary aldosteronism (PA). We investigated the effectiveness of the indices after captopril administration for prediction of unilateral hyperaldosteronism (UHA) on adrenal vein sampling (AVS). We studied 238 patients with PA who had CCT and successful AVS between July 2007 and December 2019 in Sapporo City General Hospital. Receiver operating characteristic (ROC) curve analysis showed that the diagnostic performance for prediction of UHA on AVS in regard to the reduction rate of plasma aldosterone concentration (PAC) after captopril administration was inferior to aldosterone to renin ratio (ARR) and PAC (area under the ROC curve 0.72 vs. 0.84, 0.72 vs. 0.89, respectively, both p < 0.01). Based on the optimal cut-off values in ARR (897 pg/mL/ng/mL/h, sensitivity 64.6%, specificity 93.0%) and PAC (203 pg/mL, sensitivity 73.9%, specificity 93.0%) after captopril administration, the patients were divided into three groups: (1) both positive, (2) one positive, and (3) both negative. The prevalence of UHA on AVS in the three groups were 90.0%, 52.9%, and 7.3%, respectively. In the first group, 31 of 32 patients with unilateral nodular lesion on CT had an ipsilateral unilateral AVS. In conclusion, the combination of post-captopril ARR and PAC is useful for prediction of laterality diagnosis on AVS. AVS is strongly recommended in patients with both positive or one positive results for the optimal cut-off values of post-captopril ARR and PAC and is weakly recommended in patients with both negative results.
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Affiliation(s)
- Norio Wada
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo 060-8604, Japan
| | - Arina Miyoshi
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo 060-8604, Japan
| | - Hiroaki Usubuchi
- Department of Radiology, Sapporo City General Hospital, Sapporo 060-8604, Japan
| | - Satoshi Terae
- Department of Radiology, Sapporo City General Hospital, Sapporo 060-8604, Japan
| | - Yui Shibayama
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo 060-8648, Japan
| | - Bunya Takahashi
- Department of Diagnostic Imaging, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo 060-8648, Japan
| | - Shuhei Baba
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo 060-8604, Japan
| | - Hajime Sugawara
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo 060-8604, Japan
| | - Shinji Obara
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo 060-8604, Japan
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Ogata M, Umakoshi H, Fukumoto T, Matsuda Y, Yokomoto-Umakoshi M, Nagata H, Wada N, Miyazawa T, Sakamoto R, Ogawa Y. Significance of aldosterone gradient within left adrenal vein in diagnosing unilateral subtype of primary aldosteronism. Clin Endocrinol (Oxf) 2021; 94:24-33. [PMID: 32854164 DOI: 10.1111/cen.14320] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/04/2020] [Accepted: 08/11/2020] [Indexed: 01/23/2023]
Abstract
CONTEXT The success rate of cannulation of the right adrenal vein is limited. The aldosterone gradient within the same adrenal vein branch is specific for aldosterone-producing adenoma. OBJECTIVE This study was performed to investigate whether the absolute aldosterone gradient within the left adrenal vein (left-AV absolute aldosterone gradient) indicates unilateral excess aldosterone. DESIGN AND SETTING A retrospective cross-sectional study in a single referral centre. PATIENTS AND METHODS In total, 123 consecutive patients with primary aldosteronism who had successful adrenal vein sampling (AVS) data were examined. The left-AV absolute aldosterone gradient was considered significant when a gradient of >4:1 in the aldosterone-to-cortisol ratio between the common trunk vein and central vein was found. MAIN OUTCOME MEASURE The prevalence of the unilateral subtype in patients with a significant left-AV absolute aldosterone gradient. RESULTS The prevalence of the unilateral subtype was higher in patients with than without a significant left-AV absolute aldosterone gradient (88.2% [15/17] vs 21.7% [23/106], P < .001). Of 60 patients with spontaneous hypokalemia, left unilateral disease on computed tomography, or both, a significant left-AV absolute aldosterone gradient was present only in patients with the unilateral subtype on AVS (42.9% [15/35]), but not in those with the bilateral subtype (0.0% [0/25]). These data were validated in an external cohort. CONCLUSION The presence of a significant left-AV absolute aldosterone gradient can be used to diagnose the left unilateral subtype of primary aldosteronism on AVS in patients with spontaneous hypokalemia, left unilateral disease on computed tomography or both.
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Affiliation(s)
- Masatoshi Ogata
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hironobu Umakoshi
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tazuru Fukumoto
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yayoi Matsuda
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Maki Yokomoto-Umakoshi
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiromi Nagata
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Norio Wada
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
| | - Takashi Miyazawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryuichi Sakamoto
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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