Live Every Week Like It’s Shark Week, Again!

Tonight the Discovery Channel will begin its annual Shark Week festival on TV. “Show me your teeth,” dares a singing woman, repeatedly, in the preview.

Show Me Your Teeth

I’m reminded of my thoughts on the advice – if you can call it that; it holds as a puzzle with me – from the recently-troubled Tracy Morgan as Tracy Jordan on NBC’s 30 Rock. Here’s a rerun, from last year’s ML on the same:

Dialog from Jack the Writer (Season 1, Episode 4, 2006):

Tracy Jordan: But I want you to know some­thing… You and me, it’s not gonna be a one-way street. Cos I don’t believe in one-way streets. Not between people, and not while I’m driving.

Kenneth: Oh, okay.

Tracy Jordan: So here’s some advice I wish I would have got when I was your age… Live every week, like it’s shark week.


Now, five years later, I still don’t watch the Discovery Channel by choice. And I’m afraid of sharks when I’m in the water in places where they might be near. Last season, I watched 30 Rock less regularly than before, not just because of Tracy’s frequent absence, but  mainly for lack of time. Still, what I enjoy most on that show is watching Alec Baldwin, who continues to set a fabulous example of how a talented and handsome man can pick himself up after a rough patch.

Just yesterday I was swimming in the pool next to people in scuba gear practicing for the real deal. I wondered if they watch Shark Week, or live by it, somehow.

How have Tracy’s words influenced me?

Well, I’m determined to get my book done, to take care of my mind and body, and to enjoy part of every single day. No deep insight, really. But true, at least for today. Maybe next year, I’ll have a more interesting thought on the subject of Shark Week. I might even watch the program.

Now, back to the real thing (what matters now: my book, my health, my family).



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Reducing Cancer Care Costs: Oncologists Need to Get a Grip on Reality, and Talk about Dying

We’ve reached the second half of our discussion on Bending the Cost Curve in Cancer Care. The authors of the NEJM paper, Drs. T. Smith and B. Hillner, go on to consider how doctors’ behavior influences costs in Changing Attitudes and Practice. Today’s point on the list: “Oncologists need to recognize that the costs of care are driven by what we do and what we do not do.”

In other words (theirs): “The first step is a frank acknowledgment that changes are needed.” A bit AA-ish, but fair enough –

The authors talk about needed, frank discussions between doctors and patients. They emphasize that oncologists/docs drive up costs and provide poorer care by failing to talk with patients about the possibility of death, end-of-life care, and transitions in the focus of care from curative intent to palliation.

They review published findings on the topic:

In a study at our institution of 75 hospitalized patients with cancer, the oncologist had initiated a discussion of advance directives with only 2 patients.31 In a prospective, multicenter study of 360 patients, only 37% of the patients and their families could recall having a discussion about impending death with the physician.32 Such a discussion is a prerequisite to good planning. Oncologists wait until symptoms appear or until they believe that nothing more can be done.33 In one study, at 2 months before their death, half the patients with metastatic lung cancer had not had a discussion with their doctors about hospice.34 This may explain why in a recent series the average length of stay in hospice for patients with lung cancer was 4 days.35

Although I have questions about the specific methods for some of these references, the bottom line is clear: Oncologists wait too long to talk with their patients about palliative or hospice care.

What they’re saying is that doctors need to get a grip on the problem (to overcome their denial and inability to talk about death), if they want to help patients come to terms with the inevitable. Doing so would save billions each year in the US, and would also spare patients from futile treatments and needless suffering.

I couldn’t agree more. It’s a potential win/win, if physicians think realistically about the situation and possible outcomes, and speak openly – and gently, no matter what, with their patients.

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Thoughts on the Death of Amy Winehouse

I feel compelled to write at least a short note on Amy Winehouse, a young woman who was found dead in her London apartment a few days ago. I don’t like to speak ill of the dead, but the truth is I was never a big fan of her music. I wasn’t fond of her highly-stylized hair or her weirdly-curved eyebrows.

Once, when I was 17, a friend told me he always tries to see the good in people, no matter how much they behaved disagreeably. Ever since he said that, it’s stuck. Today his words come through, in contemplating Amy Winehouse’s personality and short life.

I like her for her willfulness, even though it was so destructive.

Amy Winehouse, in 'Rehab' Video

Not a good medical lesson, for sure – or the message most people are telling their kids upon this “teaching moment,” but not everything I care for is just how it should be.

Yes, she should have gotten more help for her addictions. She needed it, that’s obvious. Family and friends, take note!… You can intervene and make a difference in a troubled person’s life.

But sometimes this happens in medicine, when you’re caring for a patient who smokes or drinks or smokes and drinks or does something else unhealthy, or in a family, or among friends – it’s not always so helpful to simply criticize and judge or lecture and point the person to the door.

So here’s another take: to identify something good in the person, and focus on that, and remember that.


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Mammography Update!

This week I’ve come across a few articles and varied blog posts on screening mammography. The impetus for rehashing the topic is a new set of guidelines issued by the American College of Obstetricians and Gynecologists. That group of women’s health providers now advises that most women get annual mammograms starting at age 40.

Why every year? I have no idea. To the best of my knowledge, there are no data to support that annual mammograms are cost-effective or life-saving for women in any age bracket at normal risk for BC.

Pertinent also, is a recent paper* in the Annals of Internal Medicine supporting a personalized approach to BC screening and mammography for women over the age of 40, and an editorial* to go with it.

“Talk to your doctor,” is the point for patients. (Women’s breasts are not all the same.)

“Talk with your patient,” is the point for doctors: Consider your patient’s breast density, family health history and personal preferences. Great idea!

We need an Annals paper to tell us this?

My personal view, synthesizing all the medical literature of which I’m aware, and taking account all of my prior experiences as a practicing oncologist, and not forgetting I’m a woman, now 50, who had an early-stage breast cancer discovered by a radiologist – and this is not medical advice – is as follows:

For women of normal risk, such as without a strong family history or a prior cancer:

1. Start with a baseline, digital mammogram at age 40. The image should be digital first, because this kind of technology is better for visualizing dense breast tissue which is more common in pre-menopausal, younger women and second, because digital images can more easily be shared with another doctor, for a second or more expert opinion if necessary.

2. Get mammograms every other year, unless there’s a significant abnormality that requires follow-up sooner. Until what age? Hard to say. (A complex topic… hold that thought for another post.)

3. Supplement mammography every other year with monthly self-examination of the breast. This inexpensive method of feeling one’s own breasts, regularly and methodically, has not been shown to save lives in randomized clinical trials. But I am convinced that if it’s done right – when a gynecologist, PCP, internist or other caregiver takes the time to teach her patients how to do the breast self-exam properly  – as I used to instruct my patients in the clinic, women can help themselves to catch breast tumors early.

4. Mammograms should be done, exclusively, by appropriately-trained radiologists who spend the bulk of their time reading mammograms, performing sonograms of the breast and taking occasional biopsies, as appropriate. (Sorry, general radiologists, but that’s how it is. Would you want your mother’s breast image examined by a radiologist who also reads hip films and MRIs of the brain?) The rate of false positives is lower when mammograms are performed by specialized “breast” radiologists.

5. Take advantage of the fact that mammography centers have been regulated for nearly two decades by the FDA. Be sure that the place where you get your mammogram is MQSA-accredited.

All for now –


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Lowering Cancer Care Costs by Limiting Chemotherapy in Patients Who Aren’t Responding

This is the sixth post on Bending the Cost Curve in Cancer Care, based on the 10 suggestions put forth by Drs. Smith and Hillner in the May 26 NEJM.  We’re up to number 5 on the list for changing oncologists’ behavior: by limiting further chemotherapy to clinical trial drugs in patients who are not responding to three consecutive regimens.

They’re right.

Giving one drug or combination regimen, and then another, and another, and another, to cancer patients whose tumors resist multiple regimens is more likely to cause harm than good. Oncologists need be realistic with themselves and with their patients, in a kindly way, when treatments fail.

Options to consider, besides chemo, include palliation (which can be started at any time, including before and during chemotherapy), alternative approaches (such as hormonal or immune-based therapy, for some tumors), hospice care and participation in a clinical trial, as the authors suggest, based on the patient’s condition and preferences.

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New Fairway Delivers Fresh Produce to My Neighborhood

On the local, national and nutritional fronts:

How refreshing, in this heat, that Fairway opened a new store on East 86th Street yesterday. Coincidently, Michelle Obama’s push to eliminate “food deserts” – places where it’s hard to find affordable fresh produce and other healthy foods – was highlighted this week when several big retailers signed on to the initiative.

PHOTO CREDIT: DNAinfo/Amy Zimmer (Manhattan Local News)

There was a carnival-like atmosphere on the sidewalk outside the new store, which occupies a large, multilevel space where there used to be a Circuit City (bankrupt, closed) and a Barnes & Noble (moved). Inside, I made a rough tally of unpackaged (6 varieties), nectarines (4), plums (3), string beans (4, including a yellow variant I’ve never seen before), potatoes (11 non-sweet, +  yams and “yellow yams”), onions (7), mushrooms (5), not counting the pre-packaged kinds), peppers (11), tomatoes (9) and beets (3).

You get the picture: if you’re looking for a fresh ingredient and it’s available anywhere New York, chances are you can find it here. Downstairs, there’s fresh fish, meat, coffees, baked goods, and tons of regular and organic grocery items. I counted 22 types of pure honey, not including differently-sized items of the same brand and flavor, and then stopped. Upstairs, there’s a limited selection of prepared foods, a competitively-priced smoked fish counter, a wide cheese selection, dried fruits, nuts and more.

I spent a while meandering through, and heard only positive comments. The shoppers seemed happy; the employees registered glee. A woman next to me on a briskly-moving line summed up the consensus: “This is the best thing that’s happened to the neighborhood in years.”

We should all be so lucky –

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The Big C: Cathy Goes For Treatment

In this week’s episode, Boo!, Cathy wakes up in the morning eager and ready to start treatment on a clinical trial. The day doesn’t go well – the local treatment center doesn’t have needed information about her insurance, which can’t be tracked down on time, her 15 year old son gets in trouble at school, and her husband loses his job.

That kind of day – when it seems like everything possible that can go wrong, goes wrong – will seem familiar to many if not all cancer patients. 

But the show continues to fail in providing any meaningful cancer information whatsoever. OK, I’m starting to accept the fact that ratings would suffer if the doctor gave even a 30 second mini-talk on BRAF mutations in melanoma. There will be no science on Showtime. But the scriptwriters could, at least, have included the discussion of the doctor and Cathy’s signing informed consent for the trial. There’s not a word about what treatment she’s getting, or what the shots she took in the last episode were for.

You’ve got to wonder if Laura Linney’s character, the “patient,” understands the purpose of the trial she’s on, the nature of the experimental treatment and risks.  The FDA approved Yervoy (ipilimumab) for patients with advanced melanoma months ago (considered here). Did her oncologist offer her that drug and, if so, why did she choose the clinical trial? Might the oncologist have a conflict of interest, in regard to the research? Is Cathy enrolled in a Phase I, II or III trial?

Please tell me something about her treatment! So far I see the Big C as a lost opportunity for teaching about cancer medicine – through humor and the potential talent of a terrific actress, or about meaningful and realistic patient-doctor relationships, or about informed consent.

If I hadn’t said I would follow the show and post on it this season, I’m not sure I’d bother watching it any further.

But I’m a compulsive sort of doctor-blogger-patient: I’ll keep watching it, at least for this year’s episodes, and I’ll keep you posted, in case you care about Cathy’s predicament, or if you want to share her thoughts on the show.

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Med-Blog Grand Rounds Takes a Virtual Tour

Live, from New York, it’s med-blog Grand Rounds, volume 7, number 43!

As I’m staying home for the summer, I’ve asked bloggers to share images of where they’re from, or where they go, so we could take a virtual tour together:

Washington Monument, at the U.S. National Mall, Wikimedia Commons (WC) image

We’ll start with a post from the Washington, DC-based Prepared Patient Forum, where Jessie Gruman clarifies that Engagement Does Not Mean Compliance. As Jessie says, “I am compliant if I do what my doctor tells me to do. I am engaged, on the other hand, when I actively participate in the process of solving my health problems.”

Heading north, to Philly –

Philadelphia City Hall, from the steps of the Art Museum (image courtesy of Bill Strouse)

Here, steps away from the Liberty Bell and Independence Hall, Ryan DuBosar covers a hot topic for the ACP Internist blog. In But wait! I wasn’t ready for you yet, he comments on CNN’s recent report that some patients are starting to bill their physicians for wait time.

On I-95, delays in Connecticut…or Amtrak…

Ether, or Good Samaritan, Statue in Boston Public Garden (WC image)

Writing in Boston, David Williams of the Health Business Blog presents the fourth and final segment in a series: Harvard Pilgrim CEO Eric Schultz holds forth on social media and mobile apps. I might’ve gone with a Pilgrim or Plymouth image to accompany this post – by association and flight of ideas, but David was kind enough to teach me something about medicine that can be learned in the Boston Public Garden, where the Ether Monument depicts an early use of anesthesia. Cool.

Wildflowers, Mass Audubon Broadmoor Wildlife Sanctuary in Natick (image courtesy of Paul Levy)

Nearby, Paul Levy likes to take hikes in places like central Massachusetts. Now that he’s Not Running a Hospital, he takes on Google+, the latest social media entry, and summarizes so many of potential connectors in Google+: Cutting down on the irrelevant cruft?. In this timely post, Paul asks the official ML question of the month: “Is it worth it?”

(No answers yet on the non-metaphysical question.) An added perk is a Tuesday term I was inspired to look up: cruft. Thanks, Paul; it’s always good to know more stuff…

Shifting gears, and possibly vehicles, somehow we arrive in Dayton, Ohio:

Dayton Ohio skyline (image courtesy of Hank Stern)

In Dayton, with a skyline I’ve never seen, Hank Stern shares his thoughts on what he calls, um, the Best Little House Down Under, he suggests that Australia’s national health system leads some people to fund their health care needs through tricky career moves, at InsureBlog.

Venturing southward…

Louisville KY, along a bike route (courtesy of J. Mandrola)

John Mandrola writes from Louisville, where he practices cardiology, posts as Dr. John M, and cycles a lot. In Having a Hand to Hold, he considers the value of stable, long-term relationships in cardiac health.

Dr. R. Bates cools her feet in the reflecting pond, at the Clinton Presidential Library in Little Rock

In Little Rock, Arkansas, we’ll find plastic surgeon Ramona Bates. In her free time, Ramona quilts and posts at Suture for a Living. She’s been concerned about the heat wave, and recommends an “oldie but relevant” post on heat-related illnesses. Given how the weather’s been here and elsewhere, we should all probably take a break and read her wise words.

A postcard arrives from the Windy City, of Oklahoma!

After planning our route, John Schumann, an internist who’s been teaching in Chicago and posting at Glass Hospital, sent word that he’s moving, for real. He and his wife are taking on new positions in Tulsa, in August. Meanwhile you can read his Debunking Urban Medical Legend, on dealing with patients who want to sign out AMA. Or you can catch an embedded, education video featuring the doctor in a cameo role as a recalcitrant patient.

Hard to know, sometimes, exactly where the news is coming from. Which leads me to our next post:

cornstalks, in the U.S. (FEMA image, WC)

Happy, the Happy Hospitalist, confided that he might be somewhere near a corn field. So I’ve placed the hospitalist at the heart of our nation’s map, figuratively and not literally, and definitely not with certainty. In a recent post on hospitals’ skyrocketing payments to hospitalists, Happy explains why they’re worth it.

On vacation –

Michael Kirsch, MD Whistleblower and Ohio gastroenterologist, recently visited Denver. He inadvertently submerged his iPhone into a pool where he took a dip, and then pondered An iPhone App for Medical Checklists? What’s truly remarkable is that Scientific American picked up on Michael’s situation so promptly; they got right on the case and immediately published a proposal to waterproof iPhones.

You’ve gotta have friends –

While in Colorado, we might visits some bloggers who live there:

view of Longs Peak, in the Front Range of the Colorado Rockies (image courtesy of Philip Hickey)

Upon hesitation, I share a post from Behaviorism and Mental Health – “an alternative perspective on mental disorders.” Philip Hickey, a retired psychologist, considers “the spurious medicalization of problems of living” in Natural Correction. I’m not sure where the he’s coming from, exactly, but the author does offer an idyllic view of the Rocky Mountains from his living room window.

Hard to find a perspective like this in Manhattan –

Somewhere else in that big, central state, Louise writes about Hospital Mergers and teamwork for the Colorado Health Insurance Insider.

Now, going to where wild things are:

grizzly bear (image from Healthline)

In Stanford, CA, Paul Auerbach is as an accomplished ER physician and professor. According to Healthline, where Paul posts regularly, he’s authored definitive books on subjects like “Wilderness Medicine” (now in its 5th Edition) and “Medicine for the Outdoors.” Just this week, he wrote on How to Prevent Fatal Bear Attacks.

Wow. (For someone in my shoes, this is about as exotic as medicine gets.) Seriously, do they teach this at Stanford?) More posts from the Bay area:

San Quentin, with inmates looking toward the distance (courtesy of Dr. Tony Brayer)

Perhaps the most isolated, provocative source for a post comes from Toni Brayer of Everything Health, who writes on her experiences playing tennis with inmates at San Quentin. Better than my writing on it, go take a look at her fabulous perspective: “As I scan the horizon I see the hills of Marin County…then my eyes stop at a guard tower with guards holding guns.”

If you’re getting tired from so much virtual travel, don’t worry: there’s sex and a mystery sign ahead to grab your possibly-flagging attention:

Golden Gate Bridge and Citgo Sign (mash-up image, courtesy of Barbara Kivowitz)

What Do You Do When Illness Makes Sex Impossible? asks Barbara Kivowitz at In Sickness and In Health. She’s sometimes in San Francisco, and sometimes in a place that sports Citgo signage. Barbara offers a hybrid, unevenly-weighted mash-up pic of her blogging spots. Analyze that!

Heading north, along the Pacific coast, you might opt for these detours –

From Portland, physician and author Doug Perednia writes The Road to Hellth <sic>. In a lively-titled post, How Can We Apply “Primum Non Nocere” to Government? – Part III, he considers how the principle of “First, do no harm” might be applied to laws and regulations about medicine and healthcare. Check it out!

Nearby, in Vancouver, clinical psychologist Will Meek usually considers human relationships at Vancouver Counselor. Recently, he posted on his insights from stressed-out animals.

Speeding along, we reach Canada’s western coast –

Victoria, Capitol of British Columbia, image courtesy of Carolyn Thomas

Carolyn Thomas, of Heart Sisters, posts from British Columbia’s capital city of Victoria. She reviews some Surprising Trends in Women’s Heart Disease in an interview with cardiologist Dr. Tracy Stevens, and reminds us that physicians are still practicing medicine based on cardiac studies performed mostly on white, middle-aged men.”

No kidding –

A few notes from our far-flung correspondents:

Sydney, Australia (WC image)

In Sydney, Australia, rheumatologist Irwin Lim at BJC Connected Care considers how a case of Ankylosing Spondylitis took on a life of its own. He describes how a determined group of rheumatologists, physiotherapists, a willing pharmaceutical company and patient advocates came together to raise awareness and help people with a rare autoimmune disease.

Trinity College, Dublin (WC image)

Paul O’Connor covered a June Conference at Trinity College, Dublin, on Links Between Arts and Health Care in his Ars Medica blog. After taking in a lot of broad range of presentations, he wonders “Can reading & appreciating the arts provide doctors with clinically relevant insights?”

Nearing the end of our trip, and my home, Peggy Polaneczky at The Blog That Ate Manhattan tells how she manages results in her EMR inbox. This could be a dreaded task for any doctor after a long vacation or any day in a women’s health practice, but Peggy makes it all seem easy.

Finally, Fizzy, an anonymous blogger at one of the first blogs I ever read, Mothers in Medicine, asks Is 12 Weeks Long Enough? She considers the pressure some pregnant women feel to work right up until delivery, so as not to lose a day of covered time off with a new baby. Seems like this could happen anywhere, and everywhere.

Spaceship Earth, at Epcot (WC image)

Well, I hope you enjoyed this medical-health tour, not of the “other” kind. It’s nice, sometimes, to just relax, put your feet up, and take in the views of others.

Many thanks to all the contributors, for sharing of themselves, beyond the posts,


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Reducing Cancer Care Costs: Why Not Offer Neulasta in Smaller Vials?

This is the fifth in a series of posts on how we might reduce the costs of cancer care, based on 10 suggestions offered in a May, 2011 NEJM sounding board. We’re up to point 4:  oncologists should replace the routine use of white-cell-stimulating factors with a reduction in the chemotherapy dose in metastatic solid cancers.

In this section, the authors allude to what I think might be a cost-saving advance in oncology practice: why not make available lower doses of white blood cell (WBC) colony stimulating factors?

The issue is this: when people get high doses of chemotherapy, they’re compromised because the bone marrow doesn’t create new WBCs as it should. The risk of infection during chemo used to be so great that, in the 1980s and earlier, it was common for cancer patients to succumb to infection. With the advent of WBC stimulants in the early 1990s, the risks of infection during chemo dropped markedly.

These are complex and expensive drugs. And while I agree with the NEJM authors that chemotherapy is over-used, often, I don’t think it makes sense to cut down on potentially helpful doses or combinations of those drugs just because WBC stimulants are expensive.

Take Neulasta (pegfilgrastim), a long- acting stimulator of neutrophils manufactured by Amgen. This injectible drug costs over $ 2,000 for a single, 6 milligram vial. It’s supposed to be given every 2 weeks, although some oncologists might give it at a lesser frequency, depending on the chemo cycles. There’s only one size dose available for all patients; they’re all billed for the full 6 milligrams.

This is an ideal situation for Amgen, which takes in over $2000 for each 6 milligram vial. It’s far from perfect for patients who, even if there’s no toxicity, pay huge co-pays with each chemo cycle.

You can find some patients’ discussions of this issue at cancer support sites like these. There’s also a public correspondence between Medicare and the State of Wisconsin on the high costs of this drug.

Around 10 years ago, when I was practicing, I wondered why we couldn’t give some patients less than 6 milligrams of Neulasta. This would be useful in at least three situations: for patients who are physically small; for those who receive lower doses of chemo; and for people who are hyper-sensitive, for whom just a tiny bit is enough to raise the white count adequately. A frequent toxicity is bone pain; this is intense in some patients and, in theory, would be less problematic if a lower dose were available. Once, I almost got into administrative trouble for asking a pharmacist to draw up only half of the dose from a vial so that I might give a petite woman only 3 milligrams of this powerful drug.

Since then, nothing’s changed. I looked it up yesterday; there’s still only one dose of Neulasta: 6 milligrams.

So if Neulasta were sold in lower-dose vials, like 1, 2, 3 or 4 milligrams, patients could receive lesser doses, as is often appropriate. The costs of these drugs, when administered properly, might be halved, approximately, without compromising on recommended doses of chemotherapy.

Just my two cents, nothing more –

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The Trouble With Placebos

The latest NEJM features a big story about a small trial, with only 39 patients in the end, on the potential for placebos to relieve patients’ experience of symptoms. This follows other recent reports on the subjective effectiveness of pseudo-pharmacology.

My point for today is that placebos are problematic in health care with few exceptions. First, in clinical trials, patients sometimes agree to take what might be a placebo so that researchers can measure effects of a drug, by comparison. A second instance is, possibly, when doctors treat children. Even then, I’m not sure it’s wise to “train” kids to take a pill and expect to feel better.

The relationship of an adult patient with a physician involves, or should involve, trust and mutual respect. A person cannot possibly give informed consent for a treatment he or she doesn’t know about. So if the doctor’s giving a placebo to the patient, and making the decision for the patient because it might help, that diminishes the patient’s autonomy, or self-determination. In simpler terms, it’s condescending.

You might consider the hypothesis that there’s nothing wrong with something if it makes you, or someone else, feel better. But that’s kind of like saying the ends justify the means.

A placebo is, by definition, manipulative. I wouldn’t want any doctor to treat me that way.

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