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Horga A, Saenz R, Yilmaz G, Simón-Campos A, Pietropaolo K, Stubbings WJ, Collinson N, Ishak L, Zrinscak B, Belanger B, Granier C, Lin K, C Hurt A, Zhou XJ, Wildum S, Hammond J. Oral bemnifosbuvir (AT-527) vs placebo in patients with mild-to-moderate COVID-19 in an outpatient setting (MORNINGSKY). Future Virol 2023:10.2217/fvl-2023-0115. [PMID: 37928891 PMCID: PMC10621114 DOI: 10.2217/fvl-2023-0115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 09/29/2023] [Indexed: 11/07/2023]
Abstract
Aim: This phase III study assessed the efficacy/safety/antiviral activity/pharmacokinetics of bemnifosbuvir, a novel, oral nucleotide analog to treat COVID-19. Patients & methods: Outpatient adults/adolescents with mild-to-moderate COVID-19 were randomized 2:1 to bemnifosbuvir/placebo. Time to symptom alleviation/improvement (primary outcome), risk of hospitalization/death, viral load and safety were evaluated. Results: Although the study was discontinued prematurely and did not meet its primary end point, bemnifosbuvir treatment resulted in fewer hospitalizations (71% relative risk reduction), COVID-19-related medically attended hospital visits, and COVID-19-related complications compared with placebo. No reduction in viral load was observed. The proportion of patients with adverse events was similar; no deaths occurred. Conclusion: Bemnifosbuvir showed hospitalization reduction in patients with variable disease progression risk and was well tolerated. Clinical Trial Registration: NCT04889040 (ClinicalTrials.gov).
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Affiliation(s)
| | | | - Gürdal Yilmaz
- Karadeniz Technical University, Trabzon, 61080, Turkey
| | | | | | | | - Neil Collinson
- Roche Products Limited, Welwyn Garden City, AL7 1TW, Hertfordshire, UK
| | - Laura Ishak
- Atea Pharmaceuticals, Inc, Boston, MA 02110, USA
| | | | | | - Catherine Granier
- Roche Products Limited, Welwyn Garden City, AL7 1TW, Hertfordshire, UK
| | - Kai Lin
- Atea Pharmaceuticals, Inc, Boston, MA 02110, USA
| | - Aeron C Hurt
- F. Hoffmann-La Roche Ltd, Basel, 4070, Switzerland
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Hammond J, Leister-Tebbe H, Gardner A, Abreu P, Bao W, Wisemandle W, Baniecki M, Hendrick VM, Damle B, Simón-Campos A, Pypstra R, Rusnak JM. Oral Nirmatrelvir for High-Risk, Nonhospitalized Adults with Covid-19. N Engl J Med 2022; 386:1397-1408. [PMID: 35172054 PMCID: PMC8908851 DOI: 10.1056/nejmoa2118542] [Citation(s) in RCA: 1145] [Impact Index Per Article: 572.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Nirmatrelvir is an orally administered severe acute respiratory syndrome coronavirus 2 main protease (Mpro) inhibitor with potent pan-human-coronavirus activity in vitro. METHODS We conducted a phase 2-3 double-blind, randomized, controlled trial in which symptomatic, unvaccinated, nonhospitalized adults at high risk for progression to severe coronavirus disease 2019 (Covid-19) were assigned in a 1:1 ratio to receive either 300 mg of nirmatrelvir plus 100 mg of ritonavir (a pharmacokinetic enhancer) or placebo every 12 hours for 5 days. Covid-19-related hospitalization or death from any cause through day 28, viral load, and safety were evaluated. RESULTS A total of 2246 patients underwent randomization; 1120 patients received nirmatrelvir plus ritonavir (nirmatrelvir group) and 1126 received placebo (placebo group). In the planned interim analysis of patients treated within 3 days after symptom onset (modified intention-to treat population, comprising 774 of the 1361 patients in the full analysis population), the incidence of Covid-19-related hospitalization or death by day 28 was lower in the nirmatrelvir group than in the placebo group by 6.32 percentage points (95% confidence interval [CI], -9.04 to -3.59; P<0.001; relative risk reduction, 89.1%); the incidence was 0.77% (3 of 389 patients) in the nirmatrelvir group, with 0 deaths, as compared with 7.01% (27 of 385 patients) in the placebo group, with 7 deaths. Efficacy was maintained in the final analysis involving the 1379 patients in the modified intention-to-treat population, with a difference of -5.81 percentage points (95% CI, -7.78 to -3.84; P<0.001; relative risk reduction, 88.9%). All 13 deaths occurred in the placebo group. The viral load was lower with nirmatrelvir plus ritonavir than with placebo at day 5 of treatment, with an adjusted mean difference of -0.868 log10 copies per milliliter when treatment was initiated within 3 days after the onset of symptoms. The incidence of adverse events that emerged during the treatment period was similar in the two groups (any adverse event, 22.6% with nirmatrelvir plus ritonavir vs. 23.9% with placebo; serious adverse events, 1.6% vs. 6.6%; and adverse events leading to discontinuation of the drugs or placebo, 2.1% vs. 4.2%). Dysgeusia (5.6% vs. 0.3%) and diarrhea (3.1% vs. 1.6%) occurred more frequently with nirmatrelvir plus ritonavir than with placebo. CONCLUSIONS Treatment of symptomatic Covid-19 with nirmatrelvir plus ritonavir resulted in a risk of progression to severe Covid-19 that was 89% lower than the risk with placebo, without evident safety concerns. (Supported by Pfizer; ClinicalTrials.gov number, NCT04960202.).
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Affiliation(s)
- Jennifer Hammond
- From Global Product Development, Pfizer, Collegeville, PA (J.H., H.L.-T.); Global Product Development (A.G.) and Early Clinical Development (M.L.B.), Pfizer, Cambridge, MA; Global Product Development, Pfizer, New York (P.A., W.B., B.D., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Medical and Safety, Pfizer, Sandwich, United Kingdom (V.M.H.); Köhler and Milstein Research, Mérida, Yucatan, Mexico (A.S.-C.); and Global Product Development, Pfizer, Tampa, FL (J.M.R.)
| | - Heidi Leister-Tebbe
- From Global Product Development, Pfizer, Collegeville, PA (J.H., H.L.-T.); Global Product Development (A.G.) and Early Clinical Development (M.L.B.), Pfizer, Cambridge, MA; Global Product Development, Pfizer, New York (P.A., W.B., B.D., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Medical and Safety, Pfizer, Sandwich, United Kingdom (V.M.H.); Köhler and Milstein Research, Mérida, Yucatan, Mexico (A.S.-C.); and Global Product Development, Pfizer, Tampa, FL (J.M.R.)
| | - Annie Gardner
- From Global Product Development, Pfizer, Collegeville, PA (J.H., H.L.-T.); Global Product Development (A.G.) and Early Clinical Development (M.L.B.), Pfizer, Cambridge, MA; Global Product Development, Pfizer, New York (P.A., W.B., B.D., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Medical and Safety, Pfizer, Sandwich, United Kingdom (V.M.H.); Köhler and Milstein Research, Mérida, Yucatan, Mexico (A.S.-C.); and Global Product Development, Pfizer, Tampa, FL (J.M.R.)
| | - Paula Abreu
- From Global Product Development, Pfizer, Collegeville, PA (J.H., H.L.-T.); Global Product Development (A.G.) and Early Clinical Development (M.L.B.), Pfizer, Cambridge, MA; Global Product Development, Pfizer, New York (P.A., W.B., B.D., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Medical and Safety, Pfizer, Sandwich, United Kingdom (V.M.H.); Köhler and Milstein Research, Mérida, Yucatan, Mexico (A.S.-C.); and Global Product Development, Pfizer, Tampa, FL (J.M.R.)
| | - Weihang Bao
- From Global Product Development, Pfizer, Collegeville, PA (J.H., H.L.-T.); Global Product Development (A.G.) and Early Clinical Development (M.L.B.), Pfizer, Cambridge, MA; Global Product Development, Pfizer, New York (P.A., W.B., B.D., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Medical and Safety, Pfizer, Sandwich, United Kingdom (V.M.H.); Köhler and Milstein Research, Mérida, Yucatan, Mexico (A.S.-C.); and Global Product Development, Pfizer, Tampa, FL (J.M.R.)
| | - Wayne Wisemandle
- From Global Product Development, Pfizer, Collegeville, PA (J.H., H.L.-T.); Global Product Development (A.G.) and Early Clinical Development (M.L.B.), Pfizer, Cambridge, MA; Global Product Development, Pfizer, New York (P.A., W.B., B.D., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Medical and Safety, Pfizer, Sandwich, United Kingdom (V.M.H.); Köhler and Milstein Research, Mérida, Yucatan, Mexico (A.S.-C.); and Global Product Development, Pfizer, Tampa, FL (J.M.R.)
| | - MaryLynn Baniecki
- From Global Product Development, Pfizer, Collegeville, PA (J.H., H.L.-T.); Global Product Development (A.G.) and Early Clinical Development (M.L.B.), Pfizer, Cambridge, MA; Global Product Development, Pfizer, New York (P.A., W.B., B.D., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Medical and Safety, Pfizer, Sandwich, United Kingdom (V.M.H.); Köhler and Milstein Research, Mérida, Yucatan, Mexico (A.S.-C.); and Global Product Development, Pfizer, Tampa, FL (J.M.R.)
| | - Victoria M Hendrick
- From Global Product Development, Pfizer, Collegeville, PA (J.H., H.L.-T.); Global Product Development (A.G.) and Early Clinical Development (M.L.B.), Pfizer, Cambridge, MA; Global Product Development, Pfizer, New York (P.A., W.B., B.D., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Medical and Safety, Pfizer, Sandwich, United Kingdom (V.M.H.); Köhler and Milstein Research, Mérida, Yucatan, Mexico (A.S.-C.); and Global Product Development, Pfizer, Tampa, FL (J.M.R.)
| | - Bharat Damle
- From Global Product Development, Pfizer, Collegeville, PA (J.H., H.L.-T.); Global Product Development (A.G.) and Early Clinical Development (M.L.B.), Pfizer, Cambridge, MA; Global Product Development, Pfizer, New York (P.A., W.B., B.D., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Medical and Safety, Pfizer, Sandwich, United Kingdom (V.M.H.); Köhler and Milstein Research, Mérida, Yucatan, Mexico (A.S.-C.); and Global Product Development, Pfizer, Tampa, FL (J.M.R.)
| | - Abraham Simón-Campos
- From Global Product Development, Pfizer, Collegeville, PA (J.H., H.L.-T.); Global Product Development (A.G.) and Early Clinical Development (M.L.B.), Pfizer, Cambridge, MA; Global Product Development, Pfizer, New York (P.A., W.B., B.D., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Medical and Safety, Pfizer, Sandwich, United Kingdom (V.M.H.); Köhler and Milstein Research, Mérida, Yucatan, Mexico (A.S.-C.); and Global Product Development, Pfizer, Tampa, FL (J.M.R.)
| | - Rienk Pypstra
- From Global Product Development, Pfizer, Collegeville, PA (J.H., H.L.-T.); Global Product Development (A.G.) and Early Clinical Development (M.L.B.), Pfizer, Cambridge, MA; Global Product Development, Pfizer, New York (P.A., W.B., B.D., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Medical and Safety, Pfizer, Sandwich, United Kingdom (V.M.H.); Köhler and Milstein Research, Mérida, Yucatan, Mexico (A.S.-C.); and Global Product Development, Pfizer, Tampa, FL (J.M.R.)
| | - James M Rusnak
- From Global Product Development, Pfizer, Collegeville, PA (J.H., H.L.-T.); Global Product Development (A.G.) and Early Clinical Development (M.L.B.), Pfizer, Cambridge, MA; Global Product Development, Pfizer, New York (P.A., W.B., B.D., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Medical and Safety, Pfizer, Sandwich, United Kingdom (V.M.H.); Köhler and Milstein Research, Mérida, Yucatan, Mexico (A.S.-C.); and Global Product Development, Pfizer, Tampa, FL (J.M.R.)
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Hammond J, Leister-Tebbe H, Gardner A, Abreu P, Bao W, Wisemandle W, Baniecki M, Hendrick VM, Damle B, Simón-Campos A, Pypstra R, Rusnak JM. Oral Nirmatrelvir for High-Risk, Nonhospitalized Adults with Covid-19. N Engl J Med 2022. [PMID: 35172054 DOI: 10.1056/nejmoa2118542/suppl_file/nejmoa2118542_data-sharing.pdf] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Nirmatrelvir is an orally administered severe acute respiratory syndrome coronavirus 2 main protease (Mpro) inhibitor with potent pan-human-coronavirus activity in vitro. METHODS We conducted a phase 2-3 double-blind, randomized, controlled trial in which symptomatic, unvaccinated, nonhospitalized adults at high risk for progression to severe coronavirus disease 2019 (Covid-19) were assigned in a 1:1 ratio to receive either 300 mg of nirmatrelvir plus 100 mg of ritonavir (a pharmacokinetic enhancer) or placebo every 12 hours for 5 days. Covid-19-related hospitalization or death from any cause through day 28, viral load, and safety were evaluated. RESULTS A total of 2246 patients underwent randomization; 1120 patients received nirmatrelvir plus ritonavir (nirmatrelvir group) and 1126 received placebo (placebo group). In the planned interim analysis of patients treated within 3 days after symptom onset (modified intention-to treat population, comprising 774 of the 1361 patients in the full analysis population), the incidence of Covid-19-related hospitalization or death by day 28 was lower in the nirmatrelvir group than in the placebo group by 6.32 percentage points (95% confidence interval [CI], -9.04 to -3.59; P<0.001; relative risk reduction, 89.1%); the incidence was 0.77% (3 of 389 patients) in the nirmatrelvir group, with 0 deaths, as compared with 7.01% (27 of 385 patients) in the placebo group, with 7 deaths. Efficacy was maintained in the final analysis involving the 1379 patients in the modified intention-to-treat population, with a difference of -5.81 percentage points (95% CI, -7.78 to -3.84; P<0.001; relative risk reduction, 88.9%). All 13 deaths occurred in the placebo group. The viral load was lower with nirmatrelvir plus ritonavir than with placebo at day 5 of treatment, with an adjusted mean difference of -0.868 log10 copies per milliliter when treatment was initiated within 3 days after the onset of symptoms. The incidence of adverse events that emerged during the treatment period was similar in the two groups (any adverse event, 22.6% with nirmatrelvir plus ritonavir vs. 23.9% with placebo; serious adverse events, 1.6% vs. 6.6%; and adverse events leading to discontinuation of the drugs or placebo, 2.1% vs. 4.2%). Dysgeusia (5.6% vs. 0.3%) and diarrhea (3.1% vs. 1.6%) occurred more frequently with nirmatrelvir plus ritonavir than with placebo. CONCLUSIONS Treatment of symptomatic Covid-19 with nirmatrelvir plus ritonavir resulted in a risk of progression to severe Covid-19 that was 89% lower than the risk with placebo, without evident safety concerns. (Supported by Pfizer; ClinicalTrials.gov number, NCT04960202.).
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Affiliation(s)
- Jennifer Hammond
- From Global Product Development, Pfizer, Collegeville, PA (J.H., H.L.-T.); Global Product Development (A.G.) and Early Clinical Development (M.L.B.), Pfizer, Cambridge, MA; Global Product Development, Pfizer, New York (P.A., W.B., B.D., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Medical and Safety, Pfizer, Sandwich, United Kingdom (V.M.H.); Köhler and Milstein Research, Mérida, Yucatan, Mexico (A.S.-C.); and Global Product Development, Pfizer, Tampa, FL (J.M.R.)
| | - Heidi Leister-Tebbe
- From Global Product Development, Pfizer, Collegeville, PA (J.H., H.L.-T.); Global Product Development (A.G.) and Early Clinical Development (M.L.B.), Pfizer, Cambridge, MA; Global Product Development, Pfizer, New York (P.A., W.B., B.D., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Medical and Safety, Pfizer, Sandwich, United Kingdom (V.M.H.); Köhler and Milstein Research, Mérida, Yucatan, Mexico (A.S.-C.); and Global Product Development, Pfizer, Tampa, FL (J.M.R.)
| | - Annie Gardner
- From Global Product Development, Pfizer, Collegeville, PA (J.H., H.L.-T.); Global Product Development (A.G.) and Early Clinical Development (M.L.B.), Pfizer, Cambridge, MA; Global Product Development, Pfizer, New York (P.A., W.B., B.D., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Medical and Safety, Pfizer, Sandwich, United Kingdom (V.M.H.); Köhler and Milstein Research, Mérida, Yucatan, Mexico (A.S.-C.); and Global Product Development, Pfizer, Tampa, FL (J.M.R.)
| | - Paula Abreu
- From Global Product Development, Pfizer, Collegeville, PA (J.H., H.L.-T.); Global Product Development (A.G.) and Early Clinical Development (M.L.B.), Pfizer, Cambridge, MA; Global Product Development, Pfizer, New York (P.A., W.B., B.D., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Medical and Safety, Pfizer, Sandwich, United Kingdom (V.M.H.); Köhler and Milstein Research, Mérida, Yucatan, Mexico (A.S.-C.); and Global Product Development, Pfizer, Tampa, FL (J.M.R.)
| | - Weihang Bao
- From Global Product Development, Pfizer, Collegeville, PA (J.H., H.L.-T.); Global Product Development (A.G.) and Early Clinical Development (M.L.B.), Pfizer, Cambridge, MA; Global Product Development, Pfizer, New York (P.A., W.B., B.D., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Medical and Safety, Pfizer, Sandwich, United Kingdom (V.M.H.); Köhler and Milstein Research, Mérida, Yucatan, Mexico (A.S.-C.); and Global Product Development, Pfizer, Tampa, FL (J.M.R.)
| | - Wayne Wisemandle
- From Global Product Development, Pfizer, Collegeville, PA (J.H., H.L.-T.); Global Product Development (A.G.) and Early Clinical Development (M.L.B.), Pfizer, Cambridge, MA; Global Product Development, Pfizer, New York (P.A., W.B., B.D., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Medical and Safety, Pfizer, Sandwich, United Kingdom (V.M.H.); Köhler and Milstein Research, Mérida, Yucatan, Mexico (A.S.-C.); and Global Product Development, Pfizer, Tampa, FL (J.M.R.)
| | - MaryLynn Baniecki
- From Global Product Development, Pfizer, Collegeville, PA (J.H., H.L.-T.); Global Product Development (A.G.) and Early Clinical Development (M.L.B.), Pfizer, Cambridge, MA; Global Product Development, Pfizer, New York (P.A., W.B., B.D., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Medical and Safety, Pfizer, Sandwich, United Kingdom (V.M.H.); Köhler and Milstein Research, Mérida, Yucatan, Mexico (A.S.-C.); and Global Product Development, Pfizer, Tampa, FL (J.M.R.)
| | - Victoria M Hendrick
- From Global Product Development, Pfizer, Collegeville, PA (J.H., H.L.-T.); Global Product Development (A.G.) and Early Clinical Development (M.L.B.), Pfizer, Cambridge, MA; Global Product Development, Pfizer, New York (P.A., W.B., B.D., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Medical and Safety, Pfizer, Sandwich, United Kingdom (V.M.H.); Köhler and Milstein Research, Mérida, Yucatan, Mexico (A.S.-C.); and Global Product Development, Pfizer, Tampa, FL (J.M.R.)
| | - Bharat Damle
- From Global Product Development, Pfizer, Collegeville, PA (J.H., H.L.-T.); Global Product Development (A.G.) and Early Clinical Development (M.L.B.), Pfizer, Cambridge, MA; Global Product Development, Pfizer, New York (P.A., W.B., B.D., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Medical and Safety, Pfizer, Sandwich, United Kingdom (V.M.H.); Köhler and Milstein Research, Mérida, Yucatan, Mexico (A.S.-C.); and Global Product Development, Pfizer, Tampa, FL (J.M.R.)
| | - Abraham Simón-Campos
- From Global Product Development, Pfizer, Collegeville, PA (J.H., H.L.-T.); Global Product Development (A.G.) and Early Clinical Development (M.L.B.), Pfizer, Cambridge, MA; Global Product Development, Pfizer, New York (P.A., W.B., B.D., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Medical and Safety, Pfizer, Sandwich, United Kingdom (V.M.H.); Köhler and Milstein Research, Mérida, Yucatan, Mexico (A.S.-C.); and Global Product Development, Pfizer, Tampa, FL (J.M.R.)
| | - Rienk Pypstra
- From Global Product Development, Pfizer, Collegeville, PA (J.H., H.L.-T.); Global Product Development (A.G.) and Early Clinical Development (M.L.B.), Pfizer, Cambridge, MA; Global Product Development, Pfizer, New York (P.A., W.B., B.D., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Medical and Safety, Pfizer, Sandwich, United Kingdom (V.M.H.); Köhler and Milstein Research, Mérida, Yucatan, Mexico (A.S.-C.); and Global Product Development, Pfizer, Tampa, FL (J.M.R.)
| | - James M Rusnak
- From Global Product Development, Pfizer, Collegeville, PA (J.H., H.L.-T.); Global Product Development (A.G.) and Early Clinical Development (M.L.B.), Pfizer, Cambridge, MA; Global Product Development, Pfizer, New York (P.A., W.B., B.D., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Medical and Safety, Pfizer, Sandwich, United Kingdom (V.M.H.); Köhler and Milstein Research, Mérida, Yucatan, Mexico (A.S.-C.); and Global Product Development, Pfizer, Tampa, FL (J.M.R.)
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