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He had no further ischemic episodes after increasing the dose of antireflux medication over a 6-month follow-up. Recurrent Transient Apical Cardiomyopathy (Tako-Tsubo-Like Most high-risk patients should be hospitalized. 150160, 2006. If esophageal spasms interfere with your ability to eat or drink, treatments are available. Of those with a positive cTn, 42.7% of the patients did not have ACS.3. Current Surgical Therapy. Ilva, T.J., et al., The etiology and prognostic significance of cardiac troponin I elevation in unselected emergency department patients. CR524CR529, 2004. He remained symptom-free until 6-month follow-up visit. In contrast to a type 1 MI (STEMI and NSTEMI), at type 2 MI results from an imbalance between myocardial oxygen supply and demand unrelated to acute coronary artery thrombosis or plaque rupture. The Fourth Universal Definition of MI published in August 2018 further updated the definitions of MI (summarized in Figure 1).2 This review focuses on type 1 and type 2 MIs, which are the most common types encountered by hospitalists. However, patient declined the elective EGD on his follow-up visit as he had no further episodes of nocturnal dyspnea on higher doses of antireflux medication. A chest pain unit is a specialized unit within an emergency department or a medical center; the unit is dedicated to careful monitoring and aggressive implementation of diagnostic protocols (clinical guidelines) for the evaluation of acute coronary syndrome. Merck Manual Professional Version. The likelihood of acute coronary syndrome (low, intermediate, high) should be determined in all patients who present with chest pain. A healthy esophagus usually moves food into your stomach through a series of coordinated muscle contractions. Heart Vessels. Because the cardiac and skeletal muscle isoforms of troponin T and I differ, they are known as the cardiac troponins. They are the preferred markers for the diagnosis of myocardial injury.24 Troponin T and I generally have similar sensitivity and specificity for the detection of myocardial injury. Accuracy is enhanced when the ECG is obtained in a patient with ongoing chest pain. High-sensitivity troponin tests can detect elevated troponin levels in people without symptoms of cardiovascular disease, according to a 2019 study. Relationship between dobutamine echocardiography and the elevation of cardiac troponin I in patients with acute coronary syndromes. Bastiany A, Pacheco C, Sedlak T, Saw J, Miner SES, Liu S, Lavoie A, Kim DH, Gulati M, Graham MM. Wang CH, Cherng WJ, Meng HC, Hong MJ, Kuo LT. Echocardiography. The authors declare that there is no conflict of interests regarding the publication of this paper. F. Guarner, Lazaro, Gascon, Royo, Eximan, and Herrero, Map of Digestive Disorders and Diseases, World Gastroenterology Organization, 2008, http://www.worldgastroenterology.org/assets/downloads/pdf/wdhd/2008/events/map_of_digestive_disorders_2008.pdf. We present a case of an atypical presentation of GERD leading to NSTEMI, likely from demand ischemia in the setting of known severe 3-vessel native CAD as well as chronic total occlusions of venous grafts. In conclusion, there is a high prevalence of GERD in patients with CAD. high-risk TIMI or GRACE scores, or markedly elevated troponin levels. Subendocardial ischemia classically results in ST-segment depression and T-wave inversion.14 Approximately 25 percent of patients with ST-segment depression and elevated creatine kinaseMB isoenzyme (CK-MB) levels eventually develop STEMI, and 75 percent have NSTEMI. WebCauses of elevated troponin STEMI: ST elevation myocardial infarction; NSTEMI: non-ST elevation myocardial infarction; PCI: percutaneous coronary intervention; SLE: systemic lupus erythematosus; BSA: body surface area. As of Oct. 1, 2017, ICD-10 and the Centers for Medicare & Medicaid Services have a new ICD-10 diagnosis code for type 2 MI (I21.A1), distinct from NSTEMI (I21.4) based on updated definitions from the American College of Cardiology, American Heart Association, European Society of Cardiology, and World Heart Federation. A 12-lead ECG should be obtained within 10 minutes of presentation.7. A type 2 MI is a relative (as opposed to an absolute) deficiency in coronary artery blood flow triggered by an abrupt increase in myocardial oxygen demand, drop in myocardial blood supply, or both. A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Morrow, and P. Jarolim, Earlier detection of myocardial injury in a preliminary evaluation using a new troponin I assay with improved sensitivity. The results of cTn testing often guide the decision for coronary intervention. While cTn elevation in CKD necessarily leads to a higher risk for false positive ACS diagnosis, cTn values in this setting are to be taken seriously; a true positive cTn related to ACS in patients with CKD is associated with a heightened risk for mortality29 compared to non CKD patients, while an asymptomatic elevation in cTn in severe CKD is associated with an increased incidence of ACS30 and a 2- to 5-fold increase in mortality.31 Serial measurement, observing for a rise and/or fall of an elevated cTn value in a patient with CKD is recommended to differentiate ACS from non-ACS causes of cTn elevations. A spasm can reduce or block blood flow to part of the heart. WebGastrointestinal causes (eg, gastroesophageal reflux, esophageal spasm, peptic ulcer, pancreatitis, biliary disease) Musculoskeletal causes (eg, costochondritis, cervical radiculopathy) Psychiatric disorders. Spasms may cause minor to When is a troponin elevation an acute myocardial infarction? Epub 2015 Oct 27. Background: Abnormal levels of serum cardiac troponin I (cTnI) are occasionally found in patients presenting with acute coronary syndromes but having insignificant coronary artery disease. Before one concludes that an abnormal cTnI level is a false-positive result, the possibility of coronary vasospasm should be considered. R. Salvador, T. J. Watson, F. Herbella et al., Association of gastroesophageal reflux and O2 desaturation: a novel study of simultaneous 24-h MII-pH and continuous pulse oximetry, Journal of Gastrointestinal Surgery, vol. Chest-wall tenderness reduces the likelihood of acute coronary syndrome (-LR: 0.2).3. 854861, 2009. In the setting of irreversible myocardial cell injury, the contents of the cTn complex are released into circulation. Furthermore, the high prevalence of O2 desaturation was found mostly in GERD patients with primary respiratory complaints [8]. 2022 Jul 27;12(8):1124. doi: 10.3390/life12081124. Patients with type 2 MI often have a history of fixed obstructive coronary disease, which when coupled with the acute trigger facilitates the type 2 MI; however, underlying CAD is not always present. Velmahos, G.C., et al., Normal electrocardiography and serum troponin I levels preclude the presence of clinically significant blunt cardiac injury. Gibson, C.M. Copyright 2005 by the American Academy of Family Physicians. 2001 Oct;18(7):573-9. doi: 10.1046/j.1540-8175.2001.00573.x. Your healthcare provider may also order tests like an electrocardiogram if there is concern for heart damage from COVID-19 or chest X-rays to monitor for any lung damage. 167173, 2005. Some people may mistake it for heart pain, also called angina. (a) Smooth short stricture in the distal esophagus slightly proximal to the gastroesophageal junction. 14446, Lippincott-Raven, Philadelphia, Pa, USA, 4th edition, 2009. Reproduction of previous documented angina, Known history of coronary artery disease, including myocardial infarction, New transient mitral regurgitation, hypotension, diaphoresis, pulmonary edema or rales, New or presumably new transient ST-segment deviation (> 0.05 mV) or T-wave inversion (> 0.2 mV) with symptoms, Elevated cardiac troponin T or I, or elevated CK-MB, ST-segment elevation greater in lead III than in lead II, ST-segment elevation of > 2.5 mm in lead V, ST-segment depression of > 1 mm in leads II, III, and aVF, ST-segment depression of 1 mm or ST-segment elevation in leads II, III, and aVF, Measured 4 hours after onset of chest pain, Measured 10 hours after onset of chest pain. Bookshelf In acute coronary syndrome, common electrocardiographic abnormalities include T-wave tenting or inversion, ST-segment elevation or depression (including J-point elevation in multiple leads), and pathologic Q waves. Stein, R., et al., Prognostic implications of normal (<0.10 ng/ml) and borderline (0.10 to 1.49 ng/ml) troponin elevation levels in critically ill patients without acute coronary syndrome. The clinician is advised to be familiar with the broad differential diagnosis of an elevated cTn, to avoid false attribution of acute MI to a patient without an ACS. government site. 8600 Rockville Pike FOIA Misdiagnosis can have downstream repercussions. Admission of patients with an equivocal or positive result. Diagnosis requires an electrocardiogram and a careful review for signs and symptoms of cardiac ischemia. Sample Clinical Documentation Query Templates Table of (b) Multiple tertiary contractions of the distal esophagus suggestive of dysmotility. GERD may also lead to demand ischemia and cause NSTEMI through other mechanisms. Esophageal spasms can feel like sudden, severe chest pain that lasts from a few minutes to hours. Pain patterns can be identical, nitroglycerin can bring relief, interval electrocardiograms and exercise electrocardiograms generally disclose no abnormalities, coronary arteriograms may be within normal limits or nearly so, and, The magnitude of an ECG abnormality affects diagnostic accuracy. Storrow, A.B., et al., Discordant cardiac biomarkers: frequency and outcomes in emergency department patients with chest pain. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Dr. Kerley Clinical question: Does initiation of empagliflozin in hospitalized patients with acute decompensated heart failure improve clinical outcomes and symptom burden? Based on the coronary anatomy the patient was managed conservatively with optimal medical therapy with no plan for percutaneous intervention or revascularization. A 71-year-old male with a history of coronary artery disease presented to the ED with complaints of acute chest pain and respiratory In 1130 patients presenting to an emergency department (ED) without chest pain, the frequency of elevated cTn was 3.6% and was associated with an increased mortality.19 This prevalence increases further in population presenting with chest pain to 4.5%,20 while in critically ill patients without ACS, the frequency ranges from 27% to 55%.21, An elevation of cTn in such situations may in fact have an ischemic origin: a recent study demonstrated that an elevated hsTnT in patients without ACS was strongly associated with the presence and severity of coronary artery disease and heart muscle disease, implying that non-ACS cTn elevation may result from coronary ischemia in the absence of plaque rupture or coronary thrombosis; this situation of supply-demand mismatch is known as a Type II MI.22, Common causes of non-ACS cTn elevation in the acutely ill patients include severe hypertension or hypotension,23 severe upper gastrointestinal bleeding,24 as well as systemic inflammatory response syndrome (with or without acute respiratory distress syndrome); in each case, elevated cTn is often associated with myocardial dysfunction and worse prognosis.25 Severe central nervous system injury due to an acute stroke or head trauma may cause elevated cTn values.26 Lastly, cardiotoxic chemotherapy is well recognized to increase cTn, and when this occurs, it can help to identify a patient at risk for cardiomyopathy.27-28, A number of chronic diseases are associated with increased frequency of elevated cTn including infiltrative cardiac diseases (e.g. This study investigated whether coronary vasospasm could be a reason for elevated cTnI in this patient population. Abnormal Q waves usually develop within the first day, and T-wave inversion and normalization of ST segments occur within hours to days. Common examples of underlying causes of type 2 MI include acute blood loss anemia (e.g. WebThe diagnosis of esophageal spasm is used quite freely among physicians, including gastroenterologists. Thompson PD, Klocke FJ, Levine BD, Van Camp SP. However, these same conditions could cause a non-MI troponin elevation in patients without CAD and could also cause myocardial injury and troponin release by causing acute left ventricular stretch/strain. Sometimes an antidepressant, such as imipramine (Tofranil), may be prescribed. When a patient presents with chest pain or symptoms suggestive of acute coronary syndrome, vital signs should be obtained, the patient should be monitored, and a focused but careful history should be obtained. In challenging cases, cardiology consultation can help determine the MI type and/or the next diagnostic and treatment considerations. Esophageal spasm: Causes, symptoms, and treatments Cardiac catheterization revealed chronic three-vessel coronary artery disease, with 2 patent grafts and 2 chronically occluded grafts. Compared to patients without GERD, patients with GERD were found to have significantly higher number of ST-segment depression episodes and total ischemic burden. spasm Required fields are marked *. Many people find that there are specific triggers that prompt esophageal spasms. sharing sensitive information, make sure youre on a federal Normal troponin levels: Healthy ranges and what high levels mean https://www.merckmanuals.com/professional/gastrointestinal-disorders/esophageal-and-swallowing-disorders/diffuse-esophageal-spasm#. Chauhan et al. But sometimes the spasms are frequent and can prevent food and liquids from traveling through the esophagus. However, elevated troponin doesnt always mean cardiac damage. Park JY, Kang EJ, Kim MH, Yong HS, Rha SW. PLoS One. The test results should be available within 30 to 60 minutes, because elevated troponins are helpful in identifying the patients who benefit most from early Early markers of acute ischemia include myoglobin and creatine kinaseMB subforms (or isoforms), when available. Elevation of cTn in the context of HF often occurs in the absence of coronary ischemia, and frequently occurs even in the absence of coronary artery disease. Common examples of underlying causes of non-MI troponin elevation include: Some underlying conditions can cause a type 2 MI or a non-MI troponin elevation depending on the clinical context. Accessed Oct. 6, 2020. Becattini, C., M.C. Although protocols for chest pain units may vary somewhat, one protocol28 that has been shown to be safe and cost-effective in an intermediate-risk population consists of the following: 1. This lack of blood supply can be due to an acute absolute or relative deficiency in coronary artery blood flow. It is underappreciated that GERD can potentially cause myocardial ischemia by increasing myocardial oxygen demand or by decreasing myocardial oxygen supply (esophagocardiac reflex). 2, pp. eCollection 2022. 5, pp. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Elsevier; 2020. https://www.clinicalkey.com. The site is secure. Elevation of cardiac troponin I indicates more than myocardial ischemia. Clin Invest Med 2003; 26:133. Turer AT, Addo TA, Martin JL, et al. Myocardial ischemia induced by rapid atrial pacing causes troponin T release detectable by a highly sensitive assay: insights from a coronary sinus sampling study. J Am Coll Cardiol 2011; 57:2398. Occasionally, reciprocal ST-segment depression occurs in leads that are electrically opposite to the area of injury. Cardiac Tn is elevated in up to 18% of patients with AAD,8 indicative of the high acuity of illness than specific to aortic dissection itself, although coronary artery occlusion in this setting is well-described.9 Misdiagnosis of AAD may potentially result in incorrect administration of anticoagulation therapy, or lead to a risky delay in the correct diagnosis.10, Another common non-ACS cause of chest pain and cTn elevation is pulmonary embolism (PE).11 The frequency of elevated cTn is 10-50% in such patients,12-13 and may be related to a combination of acute right ventricular strain and injury, hypoxia and tachycardia. Troponin elevation in CKD is worth discussion, as the interpretation of elevation of cTn in non-ACS patients may be difficult. Troponin levels within the normal range and probability of inducible myocardial ischemia and coronary events in patients with acute chest pain. S20S32, 2003. Epub 2017 Aug 1. UpToDate Combining a doubling of the baseline myoglobin level at two hours after symptom onset with an abnormal myoglobin test at six hours after symptom onset increases the sensitivity to 95 percent at six hours.25. Elevated cTn values outside of ACS are not uncommon and reflect cardiomyocyte necrosis from a wide array of cardiac, pulmonary and systemic diseases. Esophagus. This content does not have an English version. Cells. GI bleed), acute hypoxia (e.g. Chest pain that occurs suddenly at rest or in a young patient may suggest acute coronary vasospasm, which occurs in Prinzmetals angina or with the use of cocaine or methamphetamine. Two mechanisms have been proposed to be responsible for respiratory symptoms induced by gastric reflux: (1) vagal reflex response from stimulation of the vagus nerve by gastric acidic content, resulting in bronchoconstriction and (2) microaspiration of gastric contents causing direct irritation or trauma to the upper airway [57]. Importantly, even minimally elevated cTn levels in asymptomatic, apparently healthy older adults have been shown to be associated with adverse outcomes; having elevated cTn increased the risk of all-cause and cardiovascular mortality two-fold.6, Cardiac Tn is most commonly measured for the evaluation of chest discomfort and in this context, a rising and/or falling pattern of cTn should be interpreted as being reflective of ACS. Maeder, M., et al., Sepsis-associated myocardial dysfunction: diagnostic and prognostic impact of cardiac troponins and natriuretic peptides. Use of this type of systematic approach has the potential to improve the ability of physicians to care for patients with possible acute coronary syndrome, as well as reduce the likelihood of medical error. Esophageal Feldman M, et al., eds. Cardiac Tn elevations have been reported in patients with snake or scorpion bites, and thought to be in part due to myocardial injury by biologic toxins, vasospasm and coagulation abnormalities.28 Elevated cTn levels have been reported to be frequently elevated in asymptomatic athletes who complete endurance exercise. ISSN 1553-085X. Elevated cTn in asymptomatic CKD is common, the frequency which is dependent on the assay (cTnT > cTnI) and cut-off value used. Cardiopulmonary resuscitation (CPR): Due to physical injury to the heart from mechanical chest compressions and from electrical shocks of external defibrillation. doi: 10.1371/journal.pone.0271189. No assessment protocol or constellation of tests is totally accurate in diagnosing acute coronary syndrome. WebEsophagitis oresophagealspasm Pleurisy Costochondritis Chest wall / musculoskeletal pain Gastritis Hiatal hernia Anxiety Hyperventilation syndrome Biliary colic Peptic Ulcer Other cause(please specify) None of the above/ not applicable Troponin elevations tend to be mild, with more indolent (or even flat) troponin trajectories. Four patients staffed by one full-time nurse; 4. Despite multiple mechanisms suggested to explain its pathophysiology, there is increasing evidence that supports direct neuroadrenergic myocardial stimulation with concomitant transient, reversible, coronary vasospasm as the inciting event, either at the epicardial or arteriolar level. Chui Man Carmen Hui and Santosh K. Padala contributed equally to the paper and share first authorship. Differentiating acute coronary syndrome from noncardiac chest pain is the primary diagnostic challenge. Any patient with a history suggestive of acute coronary syndrome should be evaluated in a facility that has ECG and cardiac monitoring equipment.7 Patients with suspected acute coronary syndrome who have chest pain at rest for more than 20 minutes, syncope/presyncope, or unstable vital signs should be referred to an emergency department immediately.7 The diagnosis of acute myocardial infarction, which includes both STEMI and NSTEMI, requires at least two of the following: ischemic symptoms, diagnostic ECG changes, and serum cardiac marker elevation.8,9, The likelihood of acute myocardial infarction is extremely low in patients with a normal or nearly normal ECG who are younger than 60 years and do not have pain described as pressure or pain radiating to the arm, shoulder, neck, or jaw. They happen only After presenting our case, we review the literature on this atypical presentation of GERD causing acute coronary syndrome and discuss potential mechanisms. Despite the value of cTn for ACS diagnosis, risk stratification and management, it has become quite evident that non-ACS elevation of the marker is not uncommon. 3, pp. Short course of PPI not only resulted in fewer ischemic events, but also significantly improved the general health-related quality of life of patients [12]. The pain is often intense, and you might mistake it for heart pain, also known as angina. Esophagus Spasm - an overview | ScienceDirect Topics Y. Liu, S. He, Y. Chen et al., Acid reflux in patients with coronary artery disease and refractory chest pain, Internal Medicine, vol. 20 Patients with a normal CK-MB level but Jensen, J.K., et al., Frequency and significance of troponin T elevation in acute ischemic stroke. M. Swiatowski, B. Jacek, M. Klopocka et al., Suppression of gastric acid production may improve the course of angina pectoris and the results of treadmill stress test in patients with coronary artery disease, Medical Science Monitor, vol. The most common signs and symptoms include: Skin changes. 11th ed. This widely available marker has low sensitivity and specificity for cardiac damage. Although GERD classically presents with symptoms of heartburn and regurgitation of food contents, some patients may present with less typical extraesophageal cardiac or respiratory symptoms. While at the hospital, the patient experienced a similar episode of nocturnal dyspnea, prompting a barium esophagram, which was suggestive of a stricture in the distal esophagus from long-standing GERD. Bethesda, MD 20894, Web Policies 2016;23(2):149-54. doi: 10.5603/CJ.a2015.0072. Pain radiating to the shoulder, left arm, or both arms somewhat increases the likelihood of acute coronary syndrome (likelihood ratio [LR]: 1.6).3, Typical angina is described as pain that is substernal, occurs on exertion, and is relieved with rest. Red wine or extremely hot or cold liquids are more common culprits. In a study by Dobrzycki et al., 50 patients with angiographically proven CAD underwent simultaneous continuous ECG and esophageal pH monitoring for 24 hours to assess for ST-segment depression episodes and total duration of ischemic episodes [11]. Troponin levels typically start to elevate in the circulation within 2 to 3 hours of the onset of chest pain. Rapezzi, C., et al., Risk factors for diagnostic delay in acute aortic dissection. Recent consensus statements endorse the use of cTnI or cTnT as the biomarker of choice for such application.1 In order to maximize sensitivity for diagnosis of ACS, as well as for superior prognostication, these same consensus statements endorse the use of the lowest cTn cut-off point, down to the 99th percentile of a normal population as long as the assay used delivers imprecision < 10% at this cut-off point.1 While the most widely-used conventional cTn methods cannot deliver this combination of sensitivity and precision, novel very high sensitivity cTn (hsTn) assays have now been developed; these assays have a greatly improved detection limit (10- to 100-times lower than that of currently available commercial assays) with improved precision.2 hsTn assays are soon to be more widely used. Aviles, R.J., et al., Troponin T Levels in Patients with Acute Coronary Syndromes, with or without Renal Dysfunction. Measurement of troponins I and T and/or CK-MB at admission and six to eight hours after admission; 3. The https:// ensures that you are connecting to the Kline, J.A., et al., Surrogate markers for adverse outcomes in normotensive patients with pulmonary embolism. Most low-risk patients may undergo early exercise testing or can be discharged with careful outpatient follow-up. Accessed Oct. 6, 2020. Patients with elevated cTnI levels, compared with those with normal cTnI, were older (63 +/- 13 y vs 56 +/- 14 y, P =.032), had a higher incidence of males (78% vs 52%, P =.049) and positive ergonovine provocation tests (74% vs 30%, P <.0001), and tended to have a lower incidence of hypercholesterolemia (26% vs 48%, P =.088) and normal electrocardiograms (48% vs 70%, P =.078). Given this fact, and the emerging use of hsTn assays, clinicians should understand that cTn is not solely a biomarker of ischemic myocardial infarction (MI), and such clinicians must be well-versed in the differential diagnosis of an elevated cTn value outside of ACS, in order to avoid unnecessary and potentially harmful misdiagnosis and treatment for presumed ACS, while also avoiding delay in the correct treatment for the underlying cause of the elevated value. Diagnosing a type 2 MI requires evidence of acute myocardial ischemia (Figure 2) with an elevated troponin but must also have at least one of the following:2. An official website of the United States government. Although the ECG may be completely normal in a patient with myocardial ischemia and evolving infarction, classic ECG changes occur in STEMI.14 Within minutes, there is J-point elevation, and tall, peaked, hyperacute T waves develop; ST-segment elevation and reciprocal-lead ST-segment depression also occur. Troponin elevation in CKD is worth discussion, as the interpretation of elevation of cTn in non-ACS patients may be difficult. Elevated cTn in asymptomatic CKD is common, the frequency which is dependent on the assay (cTnT > cTnI) and cut-off value used. The rash, which can be itchy and painful, is often the first sign of dermatomyositis. Bouzas-Mosquera A, Peteiro J, Broulln FJ, Constanso IP, Rodrguez-Garrido JL, Martnez D, Yez JC, Bescos H, lvarez-Garca N, Vzquez-Rodrguez JM. Diagnosis of Acute Coronary Syndrome | AAFP Esophageal spasms - Symptoms and causes - Mayo Clinic The predictive value of the ECG varies markedly, depending on the baseline risk (pretest probability) for coronary artery disease in a given patient. Make your tax-deductible gift and be a part of the cutting-edge research and care that's changing medicine. He reported regurgitation and globus sensation described as a lump in his throat with difficulty expanding his lungs. His vital signs recorded during this episode showed an abrupt rise in blood pressure to 159/85mmHg, heart rate to 96bpm, and respiratory rate to 2224 per minute, with an oxygen saturation of 98% on 2L oxygen via nasal cannula. However, many patients with GERD may present with extraesophageal symptoms such as chest pain or discomfort mimicking angina, chronic cough, wheezing, dyspnea, globus sensation, hoarseness, or recurrent pneumonia as their primary presentation [57].
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