Letter to the Editor
Myasthenia gravis and systemic lupus erythematosus: presentation of 5 cases and PubMed review
Asociación de miastenia gravis y lupus eritematoso sistémico: aportación de 5 casos y revisión de PubMed
a Departamento de Medicina, Facultad de Medicina, Universidad de Granada, Granada, Spain
b Unidad de Enfermedades autoinmunes sistémicas, Servicio de Medicina Interna, Hospital Universitario Virgen de las Nieves, Granada, Spain
c Departamento de Medina del Trabajo, Cualtis SLU, Granada, Spain
d Servicio de Laboratorio e Inmunología, Laboratorio de Autoinmunidad, Hospital Universitario Virgen de las Nieves, Granada, Spain
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Left: coronal T2-FLAIR sequence showing hyperintensity in the right hippocampus. Right: coronal T2-weighted sequence showing the reduced volume and altered architecture of the right hippocampus. B) Implantation of foramen ovale electrodes (FOE). Top left: antero-posterior fluoroscopy image showing the left FOE. Top right: lateral radiography showing the implanted electrodes. Middle left: infratemporal extracranial position. Middle right: passage through the foramen ovale. Bottom: intracranial localisation in the mesial part of the temporal lobe (ambiens cistern).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "I.D. Freire Carlier, S.A. Andrade Rondón, F.A. Silva Sieger, I.A. Freire Figueroa, E.A. Barroso Da Silva" "autores" => array:5 [ 0 => array:2 [ "nombre" => "I.D." "apellidos" => "Freire Carlier" ] 1 => array:2 [ "nombre" => "S.A." "apellidos" => "Andrade Rondón" ] 2 => array:2 [ "nombre" => "F.A." 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Jiménez-Alonso, N. Navarrete-Navarrete, E. Jiménez-Jáimez, L. Jáimez" "autores" => array:4 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Jiménez-Alonso" "email" => array:1 [ 0 => "jjimenezalonso@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "N." "apellidos" => "Navarrete-Navarrete" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "E." "apellidos" => "Jiménez-Jáimez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "L." "apellidos" => "Jáimez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Departamento de Medicina, Facultad de Medicina, Universidad de Granada, Granada, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Enfermedades autoinmunes sistémicas, Servicio de Medicina Interna, Hospital Universitario Virgen de las Nieves, Granada, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Medina del Trabajo, Cualtis SLU, Granada, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Laboratorio e Inmunología, Laboratorio de Autoinmunidad, Hospital Universitario Virgen de las Nieves, Granada, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Asociación de miastenia gravis y lupus eritematoso sistémico: aportación de 5 casos y revisión de PubMed" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The contribution of Alba Isasi et al.,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> who present 3 patients with myasthenia gravis (MG) who developed systemic lupus erythematosus (SLE) after thymectomy, is of great importance given the rareness of this association and the scarcity of research into the causes and triggers of lupus disorder.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We searched on the PubMed database using the keywords SLE and MG, and obtained the following interesting results: the search returned 586 articles, although 483 do not report cases. The first article dates from 1961, although the first case of association of both conditions was published in 1954.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Of the 103 articles describing patients, 76 report a single case. We found a total of 180 cases from 32 different countries, mainly in Europe (54 articles/126 cases) and Asia (22 articles/24 cases). Prevalence of SLE in patients with MG was 1.12%-8.4% and prevalence of MG in patients with SLE was 1.3%. MG manifested first in more than twice as many cases; both conditions rarely presented simultaneously. Both adults and children were affected, with the great majority being women. Patients with MG and SLE were younger than those with MG only; they also showed higher prevalence of anti-acetylcholine receptor antibodies, received more immunosuppressants, more frequently underwent thymectomy, and presented a higher rate of remission.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The possible association between SLE and thymectomy in patients with MG is controversial.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> We identified 41 reported cases of SLE onset after undergoing thymectomy to treat MG, with SLE manifesting between 3 months and 40 years after surgery (mean, 10 years). Some studies suggest that thymectomy may play a role in the subsequent development of SLE, due to a defect in lymphocyte suppressive activity caused by decreased thymic hormonal activity, although other authors have been unable to confirm this in experimental studies. The thymectomies performed in some patients with MG and SLE caused no significant changes in disease activity. We should highlight 2 epidemiological studies from Norway and Sweden, which identified 8 patients with SLE among 48 with MG (8.4%) and 23 with SLE among 2045 with MG (1.12%), respectively; no association could be demonstrated with thymectomy.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> Furthermore, Fang et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> indicate that the 3 diseases most frequently associated with MG (polymyositis/dermatomyositis, SLE, and Addison disease) are all regulated by the HLA-B8-DR3 haplotype. In a recent meta-analysis, Chen et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> mention the association of the HLA-DRB1*1602 allele with different autoimmune diseases, including SLE and MG. In our review, most cases of SLE associated with MG were not related to thymectomy.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Another relevant aspect related to the MG/SLE association is hydroxychloroquine, an essential drug for patients with SLE, which may cause neuromuscular involvement/proximal muscular weakness, myasthenic syndromes, or even trigger MG relapses. Therefore, its use in patients with MG has been questioned. In our review, few articles mention use of the drug, and we found that only 10 patients did not report adverse effects, 8 patients reported doubtful adverse effects, and 4 patients poorly tolerated the drug; in general, hydroxychloroquine may be administered in the majority of cases.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">We present the cases of 5 women with SLE and MG, aged 33, 50, 62, 72, and 77 years (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). In 4 patients, SLE manifested before MG, and the remaining patient underwent thymectomy 7 years before onset of SLE. All patients received hydroxychloroquine and, although patient number 4 presented maculopathy, leading to treatment suspension, none presented MG exacerbation. All 5 patients presented mild-moderate SLE, with general, cutaneous, and articular symptoms, and laboratory and autoimmunity data indicating diagnosis of SLE; none presented involvement of vital organs, with the exception of patient 3, who died due to severe cardiac and kidney disease.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">We consider the contribution of Alba Isasi et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> to be relevant, although we believe that further well-designed, multicentre studies with sufficiently large samples and long follow-up periods are needed to determine whether thymectomy may trigger SLE in some patients with MG or whether the association between the 2 autoimmune processes is caused by other immunological/genetic causes.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-04-15" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Jiménez-Alonso J, Navarrete-Navarrete N, Jiménez-Jáimez E, Jáimez L. Asociación de miastenia gravis y lupus eritematoso sistémico: aportación de 5 casos y revisión de PubMed. Neurología. 2021;36:556–557.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Anti-AChR ab: anti–acetylcholine receptor antibodies; HCQ: hydroxychloroquine; MG: myasthenia gravis; OAE/M: ocular adverse effects/maculopathy; SLE: systemic lupus erythematosus.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Patient \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age at diagnosis of SLE \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age at diagnosis of MG \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Thymectomy \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">HCQ \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Anti-AChR ab \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Type of MG \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Well-tolerated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Generalised \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Well-tolerated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Generalised \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Well-tolerated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ocular \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">55 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">65 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Suspension due to OAE/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ocular \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">54 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Well-tolerated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ocular \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2693808.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical data of 5 patients diagnosed with systemic lupus erythematosus and myasthenia gravis.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Systemic lupus erythematosus in thymectomized patients with myasthenia gravis: reports of three clinical cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.T. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 0 | 6 |
| 2024 October | 45 | 18 | 63 |
| 2024 September | 26 | 24 | 50 |
| 2024 August | 40 | 10 | 50 |
| 2024 July | 50 | 8 | 58 |
| 2024 June | 35 | 6 | 41 |
| 2024 May | 43 | 13 | 56 |
| 2024 April | 26 | 4 | 30 |
| 2024 March | 42 | 6 | 48 |
| 2024 February | 36 | 7 | 43 |
| 2024 January | 45 | 4 | 49 |
| 2023 December | 40 | 12 | 52 |
| 2023 November | 61 | 9 | 70 |
| 2023 October | 56 | 14 | 70 |
| 2023 September | 33 | 13 | 46 |
| 2023 August | 33 | 11 | 44 |
| 2023 July | 65 | 15 | 80 |
| 2023 June | 45 | 3 | 48 |
| 2023 May | 61 | 4 | 65 |
| 2023 April | 30 | 7 | 37 |
| 2023 March | 48 | 7 | 55 |
| 2023 February | 41 | 12 | 53 |
| 2023 January | 30 | 12 | 42 |
| 2022 December | 20 | 3 | 23 |
| 2022 November | 34 | 6 | 40 |
| 2022 October | 41 | 9 | 50 |
| 2022 September | 31 | 5 | 36 |
| 2022 August | 40 | 17 | 57 |
| 2022 July | 48 | 12 | 60 |
| 2022 June | 23 | 12 | 35 |
| 2022 May | 25 | 10 | 35 |
| 2022 April | 30 | 9 | 39 |
| 2022 March | 19 | 7 | 26 |
| 2022 February | 15 | 8 | 23 |
| 2022 January | 10 | 5 | 15 |
| 2021 December | 7 | 8 | 15 |
| 2021 November | 12 | 7 | 19 |
| 2021 October | 29 | 14 | 43 |
| 2021 September | 14 | 13 | 27 |
| 2021 August | 0 | 3 | 3 |
| 2021 July | 0 | 10 | 10 |
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