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Thread: Medicine question

  1. #11
    Senior Member Broknwing's Avatar
    Join Date
    Mar 2004
    Central Florida
    Quote Originally Posted by Biker Mom
    Thanks Broknwing. I would love that recommendation too. I thought the one at Sea Pines was pretty good until finding out this antibiotic thing is out dated. What rehab in Orlando are you talking about? I am trying to look into another one. I want him to go back to Sea Pines after a year because they have an autoambulator which I think would be great for him.
    Happy New Year!
    I guess this is what I will do for the rest of this year!

    The Physiatrist that I recommend in Orlando is Dr Diana Harper. She's located 100 W Gore Street. Suite 200. If you can't find her phone number via google, PM me and I'll send it to you. Her office is located in the Orlando Orthopaedic building across the street from Orlando Regional Lucerne Rehab...Which is the AWFUL rehab I mentioned...Lucerne Rehab is the rehab I went through, their outpatient rehab is on the 1st floor of the same building Dr Harper is in, but she's NOT affiliated with them. She's affiliated with Florida Hospital & has received a number of us patients who were unhappy with Lucerne & their less than knowledgable medical director.

    The autoambulator sounds really great! Maybe you don't even have to wait an entire year before you get your husband back into their outpatient program to use it. The sooner the better to get going on something like that.

    I live way south now, near Sebring, but still go up to Orlando for my dr's b/c I'm so situated and happy with them, but I'm still trying to find a physical therapy place I'm happy with. I had a great therapist for a few sessions, but he was a floater and got sent away...the new therapist didn't bother to read my file/notes/goals and wasn't working towards what I had explicitly stated, therefore when I requested to ask for a new script for extended therapy she wouldn't request it...I don't want to go back to that onward to a new therapist/therapy center in the new year...
    L-1 inc 11/24/03

    "My Give-a-Damn's Busted"......

  2. #12

    Urinary tract infections (UTI's) are a common problem after spinal cord injury. In the 1980's, many doctors aggressively treated urinary tract infections every time they found bacteria in the urine (bacteriuria) in patients with spinal cord injury, whether or not they had symptoms of infection (fever, elevated white blood count, cloudy urine). This practice turned out to be not only ineffective for preventing UTI's but created antibiotic-resistant bacteria that led to an escalating war with bacteria using ever more potent and toxic antibiotics. While long-term antibiotics will eliminate stray infections, some bacteria will develop resistance to the particular antibiotic. Bacteria can pass resistance to antibiotics to each other. In the early 1990's, doctors reached a consensus that they should not give antibiotics to people who have bacteriuria but do not have systemic symptoms (fever, elevated white blood counts) of UTI. Not only did rates of antibiotic-resistant bacteria associated UTI's fall but there was no increase and perhaps even a decrease in the incidence of UTI's. Thus, it is clear that antibiotics should not be used to treat asymptomatic bacteriuria. For this reason, many doctors and people are leary of using antibiotics to treat asymptomatic bacteriuria, for fear of creating more antibiotic resistant bacteria (Beiring-Sorenson, et al., 2001).

    Niew-Weise & van den Broek (2005a) reviewed the subject of prophylactic antibiotic use for UTI's after instrumentation (e.g. insertion of catheter). Five clinical trials suggested that prophylatic antibiotics treatment signficantly lowers the bacteria count in the bladder fivefold after instances of bacterial introduction. Schoof & Hill (2005) analyzed randomized clinical trials on the use of prophylactic antibiotics in women with recurrent UTI's. Ten trials with 430 women compared antibiotics with placebo. Patients that were on antibiotics had 0-0.9 infections per patient-year while those who were not on antibiotics or were on placebo had 0.8 to 3.6 infections per patient-year. They concluded that continuous antibiotic prophylaxis for 6-12 months reduced the rates of UTI. When the antibiotics were discontinued, the difference between the treated and untreated groups disappeared. One clinical trial compared the continuous or post-coital administration of ciprofloxacin (Cipro) on infection rates in women and found no difference, recommending that the antibiotics be given only after intercourse, rather than continuously.

    Long term prophylactic (preventative) antibiotic treatment of people has been debated extensively. For some people, prophylactic antibiotics may be necessary if they get a lot of UTI's. Lowder, et al. (2007) recently did an analysis of the decision making process for using prophylactic antibiotics. They found that prophylactic antibiotics reduced UTI rate from 9.2% (without antibiotics) to 5.3% (with antibiotics). They concluded that it is probably not worthwhile using prophylactic antibiotics unless the UTI rate is greater than 10%, i.e. the person has a UTI's more than 10% of the time. In children, the use of long-term prophylactic antibiotics may be be useful up to age 5 (Abeysekara, et al., 2006), although more rigorous and long-term control studies are necessary to establish the safety and efficacy of long-term prophylactic antibiotic use in children (Blumental, 2006). Thus, there is some clinical trial evidence that 6-12 month course of antibiotics will reduce the incidence of UTI's in women and children who have recurrent UTI's, particularly when it occurs more than 10% of the time.

    What about people with spinal cord injury undergoing intermittent catheterization in spinal cord injury? Clarke, et al. (2005) did a randomized controlled trial which studied 85 children who had been placed on antibiotics for a UTI and then randomized to either continued antibiotics or discontinuation of antibiotics. The results paradoxically suggest a significant increase in UTI's in children who had the continued antibiotics. The authors concluded that "use of prophylactic antibiotics for children who intermittently catheterize may not be necessary" and "may result in increased rates of infection because of the development of resistant organisms."

    What about people with long-term bladder drainage, e.g. foley catheters? Niel-Weise & van den Broek (2005b) reviewed this subject. For patients who used intermittent catheterization, antibiotic prophylaxis had inconsistent effects on symptomatic UTI's. There was limited evidence that prophylactic antibiotics reduced the rates of bacteriuria (whether symptomatic or not). However, for patients on long-term bladder drainage, one trial reported fewer episodes of symptomatic UTI in the patients receiving long-term prophylactic treatments. Use of prophylatic antibiotics for people with long-term bladder drainage is controversial.

    So, some evidence supports use of short-erm prophylactic antibiotics after instrumentation (i.e. urodynamic study). Likewise, there is weak evidence that prophylactic antibiotics will reduce UTI's in patients with long-term bladder drainage with urethral foley catheters. However, there is little or no evidence suggesting that long-term prophylactic antibiotics reduces bacteriuria or infection in people with intermittent catheterization. There may be some alternatives to antibiotics. For example, some doctors believe that cranberry reduce bacteria in the urine (Bruyere, 2006) but this is a big subject.


    1. Abeysekara CK, Yasaratna BM and Abeyanunawardena AS (2006). Long-term clinical follow up of children with primary vesicoureteric reflux. Indian Pediatr 43: 150-4. Fifty-six children (35 boys and 21 girls) below the age of 12 years with primary Vesicoureteric reflux (VUR) detected by voiding cystourethrogram after an initial episode of documented urinary tract infection (UTI), were studied prospectively for a period of 6-12 years (Mean 8 years) with reference to scarring, grade of reflux, break-through infections, adverse effects to prophylactic drugs and clinical and laboratory evidence of renal failure. The mean age at presentation was 1.95 years. Grade I-V reflux occurred in 7.1%, 28.6%, 48.2%, 12.5%, 3.6% respectively. Thirty-one (55.3%) had detectable renal scars on dimercaptosuccinic acid (DMSA) scan. All of them were treated with low dose prophylactic antibiotics until the age of 5 years. None had any major adverse effects to the prophylactic antibiotics. Ten (17.9%) had breakthrough UTI while on prophylaxis and 3 (5.4%) had UTI after discontinuing prophylaxis at 5 years of age. Two patients underwent ureteric reimplantation. Clinical and laboratory evidence of renal failure was not observed during the follow up period. Systolic blood pressure of all patients was below the 90th percentile for age. One had significant proteinuria. Majority of this cohort of patients with varying degrees of reflux nephropathy were managed conservatively with regular monitoring and low-dose prophylactic antibiotic therapy. Department of Pediatrics, Faculty of Medicine, University of Peradeniya, Sri Lanka.
    2. Biering-Sorensen F, Bagi P and Hoiby N (2001). Urinary tract infections in patients with spinal cord lesions: treatment and prevention. Drugs 61: 1275-87. Even though the mortality due to urinary tract complications has decreased dramatically during the last decades in individuals with spinal cord lesions (SCL), urinary tract infections (UTI) still cause significant morbidity in this population. Complicated UTI are caused by a much wider variety of organisms in individuals with SCL than in the general population and are often polymicrobial. Escherichia coli, Pseudomonas spp., Klebsiella spp., Proteus spp., Serratia spp., Providencia spp., enterococci, and staphylococci are the most frequently isolated bacteria in urine specimens taken from individuals with SCL. There is no doubt that the greatest risk for complicated UTI in these individuals is the use of an indwelling catheter. Intermittent catheterisation during the rehabilitation phase has been shown to lower the rate of UTI, and virtually eliminate many of the complications associated with indwelling catheters. Persons with SCL should only be treated for bacteriuria if they have symptoms. Generally, it is advisable to use antibacterial agents with little or no impact on the normal flora. Single agent therapy - in accordance with antimicrobial susceptibility test - is preferred. We advise extending treatment to at least 5 days, and in those with reinfection or relapsing UTI, at least 7 to 14 days, depending on the severity of the infection. The diagnosis of structural and/or functional risk factors is essential in order to plan an optimal treatment for UTI in individuals with SCL, which should include treatment of simultaneously occurring predisposing factors. The treatment of structural risk factors follows general urological principles, aiming for sufficient outlet from the bladder with minimal residual urine and low pressure voiding. For prevention of UTI, general cleanliness and local hygiene should be encouraged. If the patient has a reinfection or relapsing symptomatic UTI, it is important to check for inadequately treated infection and complications, which need special attention, in particular residual urine and urinary stones. No reliable evidence exists of the effectiveness of cranberry juice and other cranberry products. Prophylactic antibacterials should only be used in patients with recurrent UTI where no underlying cause can be found and managed, and in particular if the upper urinary tract is dilated. Antibacterials should not be used for the prevention of UTI in individuals with SCL and indwelling catheters. However, the use of prophylactic antibacterials for individuals with SCL using intermittent catheterisation or other methods of bladder emptying is controversial. Clinic for Para- and Tetraplegia, Copenhagen University Hospital, Rigshospitalet, Denmark.
    3. Bruyere F (2006). [Use of cranberry in chronic urinary tract infections]. Med Mal Infect 36: 358-63. OBJECTIVE: Chronic cystitis in women is frequent and difficult to treat. Up to now, an empirical prescription of antibiotics could decrease the frequency of acute episodes but with adverse effects and increasing risks of resistance. Studies have shown that cranberries should be used for that indication. We made a systematic review of literature to demonstrate how to use the cranberry. RESULTS: Randomized studies confirmed that the proanthocyanidin contained in cranberries can eliminate Escherichia coli adhesion to the urothelium. Clinical studies showed that the incidence of acute cystitis decreased when treated by cranberries. On the other hand, patients with a neurogenic bladder and intermittent catheterization do not seem to benefit from the fruit. We did not find any study on postcoital use of cranberries. Various substances and doses were used in these studies and we could not conclude on best galenic presentation to prescribe. CONCLUSION: Cranberries can inhibit E. coli adhesion to the urothelium and could be useful to treat urinary infections. Clinical studies confirm the probable benefit of this fruit as a prophylactic treatment for female cystitis. Prescriptions modalities remain to be defined. Service d'urologie, CHRU Bretonneau, 2, boulevard Tonnelle, 37044 Tours, France.
    4. Clarke SA, Samuel M and Boddy SA (2005). Are prophylactic antibiotics necessary with clean intermittent catheterization? A randomized controlled trial. J Pediatr Surg 40: 568-71. BACKGROUND/PURPOSE: Clean intermittent catheterization has been an established practice for more than 3 decades. The validity of antibiotic prophylaxis has been questioned although not tested. METHODS: Eighty-five patients were recruited into a randomized controlled trial. The randomization involved the placement into 1 of 2 groups: (A) continuing antibiotics or (B) discontinuing antibiotics. The trial would last 4 months with the outcome being a confirmed urinary tract infection. All groups were matched for age, sex, and pathology. RESULTS: The incidence of urinary tract infections was significantly increased in the group who continued to use antibiotics (n = 20) when compared with the group who discontinued prophylaxis (n = 3). The common infecting organism was Escherichia coli. CONCLUSIONS: The use of prophylactic antibiotics for children who intermittently catheterize may not be necessary. The use of prophylactic antibiotics may result in increased rates of infection because of the development of resistant organisms. Department of Paediatric Surgery, St Georges Hospital Medical School, Tooting, London, SE17 8QT, UK.
    5. Lowder JL, Burrows LJ, Howden NL and Weber AM (2007). Prophylactic antibiotics after urodynamics in women: a decision analysis. Int Urogynecol J Pelvic Floor Dysfunct 18: 159-64. The objective of this paper is to compare the risks and benefits of antibiotics to prevent urinary tract infection (UTI) after urodynamics. We developed a decision analytic model to compare the use of prophylactic antibiotics with no antibiotic use after urodynamics to prevent UTI. Risks and benefits were estimated from the literature and by consensus. The main outcome measure was the occurrence of UTI. Secondary outcomes were the development of adverse events and possible sequelae. One-way sensitivity analyses estimated the effect of varying each characteristic through its range while all other characteristics were fixed at their baseline values. The effectiveness of prophylaxis after urodynamics was a reduction of UTI from 9.2 (no antibiotics) to 5.3% (antibiotics). One-way sensitivity analysis of the probability of UTI without prophylaxis yielded a threshold infection rate of 10%, below which, the strategy of no prophylaxis was favored. In this model, prophylactic antibiotics after urodynamics are not beneficial until the rate of UTI without antibiotics exceeds 10%. Division of Urogynecology, Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, 300 Halket Street, Pittsburgh, PA, 15213, USA,
    6. Niel-Weise BS and van den Broek PJ (2005a). Antibiotic policies for short-term catheter bladder drainage in adults. Cochrane Database Syst Rev CD005428. BACKGROUND: Urinary tract infections account for about 40% of hospital-acquired (nosocomial) infections, and about 80% of urinary tract infections acquired in hospital are associated with urinary catheters. OBJECTIVES: To determine if certain antibiotic policies are better than others in terms of prevention of urinary tract infections, complications, quality of life and cost-effectiveness in short-term catheterised adults. SEARCH STRATEGY: We searched the Cochrane Incontinence Group Specialised Register (searched 20 December 2004). Additionally, we examined all reference lists of identified trials. SELECTION CRITERIA: All randomised and quasi-randomised trials comparing antibiotic policies for short-term (up to and including 14 days) catheterization in adults. DATA COLLECTION AND ANALYSIS: Data were extracted by both reviewers independently and compared. Disagreements were resolved by discussion. Data were processed as described in the Cochrane Handbook. If data had not been fully reported, clarification was sought directly from the authors of the trial. MAIN RESULTS: Six parallel-group randomised controlled trials met the inclusion criteria.In one trial comparing antibiotic prophylaxis with giving antibiotics when clinically indicated amongst female surgical patients who had a urethral catheter for more than 24 hours, symptomatic urinary tract infection was less common in the prophylaxis group (RR 0.20, 95% CI 0.06 to 0.66).Five trials compared antibiotic prophylaxis with giving antibiotics when microbiologically indicated, bacteriuria, pyuria and gram-negative isolates in patients' urine were less common in the prophylaxis group amongst surgical patients with bladder drainage for at least 24 hours postoperatively. Bacteriuria rates were also about five-fold lower in the prophylaxis group in trials involving urological surgery patients and non-surgical patients.No trial compared giving antibiotics when microbiologically indicated with giving antibiotics when clinically indicated. AUTHORS' CONCLUSIONS: There was weak evidence that antibiotic prophylaxis compared to giving antibiotics when clinically indicated reduced the rate of symptomatic urinary tract infection in female patients with abdominal surgery and a urethral catheter for 24 hours.The limited evidence indicated that receiving antibiotics during the first three postoperative days or from postoperative day two until catheter removal reduced the rate of bacteriuria and other signs of infection such as pyuria and gram-negative isolates in patients urine in surgical patients with bladder drainage for at least 24 hours postoperatively. There was also limited evidence that prophylactic antibiotics reduced bacteriuria in non-surgical patients. Medical Centre, Leiden University, C9-43 Box 9600, 2300 RC Leiden, Netherlands.
    7. Niel-Weise BS and van den Broek PJ (2005b). Urinary catheter policies for long-term bladder drainage. Cochrane Database Syst Rev CD004201. BACKGROUND: People requiring long-term bladder draining commonly experience catheter-associated urinary tract infection and other problems. OBJECTIVES: To determine if certain catheter policies are better than others in terms of effectiveness, complications, quality of life and cost-effectiveness in long-term catheterised adults and children. SEARCH STRATEGY: We searched the Cochrane Incontinence Group specialised trials register (searched 9 June 2003). Additionally, we examined all reference lists of identified trials. SELECTION CRITERIA: All randomised and quasi-randomised trials comparing catheter policies (route of insertion and use of antibiotics) for long-term (more than 14 days) catheterisation in adults and children. DATA COLLECTION AND ANALYSIS: Data were extracted by both reviewers independently and compared. Disagreements were resolved by discussion. Data were processed as described in the Cochrane Handbook. If the data in trials have not been fully reported, clarification were sought from the authors. When necessary, the incidence-density rates (IDR) and/or the incidence-density differences (IDD) within a certain time period were calculated. MAIN RESULTS: Seven trials met the inclusion criteria involving 328 patients in four crossover and three parallel-group randomised controlled trials. Only two of the pre-stated six comparisons were addressed in these trials.Three trials compared antibiotic prophylaxis with antibiotics when clinically indicated. For patients using intermittent catheterisation, there were inconsistent findings about the effect of antibiotic prophylaxis on symptomatic urinary tract infection. For patients using indwelling urethral catheterisation, one small trial reported fewer episodes of symptomatic UTI in the prophylaxis group.Four trials compared antibiotic prophylaxis with giving antibiotics when microbiologically indicated. For patients using intermittent catheterisation, there was limited evidence that receiving antibiotics reduced the rate of bacteriuria (asymptomatic and symptomatic). There was weak evidence that prophylactic antibiotics were better in terms of fewer symptomatic bacteriuria. AUTHORS' CONCLUSIONS: No eligible trials were identified that compared alternative routes of catheter insertion. The data from seven trials comparing differing antibiotic policies were sparse, particularly when intermittent catheterisation was considered separately from in-dwelling catheterisation. Possible benefits of antibiotic prophylaxis must be balanced against possible adverse effects, such as development of antibiotic resistant bacteria; these cannot be reliably estimated from currently available trials. Medical Centre, Leiden University, C9-43 Box 9600, 2300 RC Leiden, Netherlands, 0031.
    8. Schooff M and Hill K (2005). Antibiotics for recurrent urinary tract infections. Am Fam Physician 71: 1301-2. BACKGROUND: UTI is a common health care problem. Recurrent UTI in healthy, nonpregnant women is defined as three or more episodes of UTI during a 12-month period. Long-term antibiotics have been proposed as a prevention strategy for recurrent UTI. OBJECTIVES: To determine the efficacy (during and after) and safety of prophylactic antibiotics used to prevent uncomplicated recurrent UTI in nonpregnant women. SEARCH STRATEGY: The authors searched MEDLINE (1966 to April 2004), EMBASE (1980 to January 2003), Cochrane Register of Controlled Trials (in the Cochrane Library Issue 1, 2004), and reference lists of retrieved articles. SELECTION CRITERIA: Published randomized controlled trials (RCTs) in which antibiotics were used as prophylactic therapy in patients with recurrent UTI were selected. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. Statistical analyses were performed using the random-effects model, and the results were expressed as RR with a 95 percent confidence interval (CI). PRIMARY RESULTS: Nineteen studies with a total of 1,120 women were eligible for inclusion. Of these, 10 trials with 430 women compared antibiotics with placebo. During active prophylaxis, the rate of microbiologic recurrence per patient-year was 0 to 0.9 in the antibiotic group compared with 0.8 to 3.6 in the placebo group. The RR of having one microbiologic recurrence was 0.21 (95 percent CI, 0.13 to 0.34), which favored antibiotic, and the NNT was 1.85. The RR for clinical recurrences was 0.15 (95 percent CI, 0.08 to 0.28), and the NNT was 1.85. The RR of having one microbiologic recurrence after prophylaxis was 0.82 (95 percent CI, 0.44 to 1.53). The RR for severe side effects was 1.58 (95 percent CI, 0.47 to 5.28); the RR for other side effects was 1.78 (95 percent CI, 1.06 to 3.00), which favored placebo. Side effects included vaginal and oral candidiasis and gastrointestinal symptoms. Eight trials with 513 women compared antibiotics; these trials were not pooled. Weekly prophylaxis with pefloxacin was more effective than monthly prophylaxis. [NOTE: pefloxacin is a fluoroquinolone that is not available in the United States.] The RR for microbiologic recurrence was 0.31 (95 percent CI, 0.19 to 0.52). There was no significant difference in rates of microbiologic recurrence with daily and postcoital ciprofloxacin. REVIEWERS' CONCLUSIONS: Compared with placebo, continuous antibiotic prophylaxis for six to 12 months reduced the rate of UTI during prophylaxis. After prophylaxis, two studies showed no difference between groups. The treated group had more adverse events. One RCT compared postcoital and continuous daily ciprofloxacin and found no significant difference in rates of UTI, suggesting that postcoital treatment could be offered to woman who have UTI associated with sexual intercourse. Clarkson Family Medicine Residency Program, Omaha, Nebraska 68131, USA.
    Last edited by Wise Young; 01-02-2007 at 03:30 AM.

  3. #13
    Thanks for the info. I will be sending it my case manager and see what she says about us going there.

    I am glad I spoke with you because I was considering Lucerne since Brain and spinal work closely with them. I think we will just stick with Sea Pines if I can't talk my husband into making a trip to Shepard's this summer.

    Thanks for everything and good luck finding a therapist. We just changed too and it is tough.

  4. #14
    Thanks Dr. Wise. We go to the doctor today and I will further discuss it with him.

    This site has been great!

  5. #15
    Well we went to the doc today for the first time and it was a total flop. He knew very little about SCI and wasn't really sure what to tell us about meds. All he kept saying was that my husband really should be in a manual chair. DUH, we already knew that. We are working on it!

  6. #16
    Senior Member
    Join Date
    Jun 2005
    Denver, Colorado
    Hi Biker Mom!

    Yep... primary physicians generally don't see alot of SCI patients.... our MD (other than our physiatrist) didn't have much experience so it has been a learning experience for him. Most of Don's problems have been UTI related or so we thought. We thought that if Don's urine was cloudy and smelly that he must have a UTI and for the first year after injury, I found myself running back and forth with samples, which, of course showed positive. But, they went ahead and treated many times when they didn't need to because he was asymptomatic. Now... I don't panic anymore and we don't treat unless Don shows symptoms (fever, chills, pain, etc). We know he is colonized but that is part of SCI life.

    But... it's taken us almost 2 years to figure this out. Don has not been on antibiotics for UTI since July 2006 (yipeeee).

    It's important that your hubby establish with a good neuro urologist but I'm sure others have already suggested this.

    Welcome to CareCure.


  7. #17
    Thanks for your info. I knew it would be hard to find someone who has dealt with SCI before but we were given a month to find someone as his primary and our ins changed in the process. We are going to keep searching until we find someone we like.

    We are also trying to find a urologist. I didn't know there are neuro urologist. I just thought they were all consider urologist. I was given some recommendations from Broknwing, so we are going to try them.

    I am glad to hear that Don is doing well.


  8. #18
    he will always test positive post-sci. b/c he doesn't fully empty anymore, there is always something there for bacteria to grow on.

    they key is that it can be Colonized without having a full-blown infection.

    nurse - do you know what the 'saturation' level is to indicate antibiotics?

    I recently was prescribed macro-bid from an ER doctor, but know from my excellent mentor not to treat unless I am symptomatic (fever etc).

    I had to advocate for myself and make sure he based my UTI dx on more than just a positive culture.

    if you ever have to give blood, say for an operation, red cross won't accept it b/c of the + culture. I learned that the hard way.

  9. #19

    UTI prevention/cure

    I take D-Mannose supplements to keep me from getting UTIs. I am a C3-7 incomplete. I have not had a UTI since I started taking the D-Mannose several years ago. It is the raw ingredient in Mannose Magic you see advertised in the spinal cord injury magazines New Mobility and PV (Paralyzed Veterans). You can get it at your local health food store or mail order it.


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