Category Archives: Uncategorized

Summer vacation for everyone!

sunflowersSummer is here, and for many, especially those on a school schedule, this means summer vacation! Families often take this opportunity to travel together, have adventures, and spend some quality time together.

Travel is one of those things which is stressful and overwhelming for many people, but until today, I never really thought about the added burden travel could bring when one of your passengers has special needs. What if you have a child in a wheelchair? Or a child with autism? What if your child has a feeding tube? Or has visual impairment? Travel and vacation has just become much more complicated, because in addition to the typical itinerary and accommodations, you now need to research and plan for many other things specific to your family’s needs.

This morning, I was alerted to the existence of a really cool website developed to help families navigate travel with individuals with special needs. Started by a mother of two kids, one with special needs, Special Globe has tons of resources including helpful information from the CDC and TSA, tips and tricks, and even notes about how accessible various attractions are in different vacation spots.

While I know this post isn’t as applicable to most, chances are, you know someone who might benefit from this information. Pass it around! Have a great summer!

Tay-Sachs and BRCA Testing on the Same Day?

Can you also test me for BRCA while I am here already?” asked my 21 year old patient. He was in my office about a month before he was planning on proposing to his girlfriend. He came because he knew his sister was an FD carrier and he wanted to get screened for this condition as well as others that are common in Ashkenazim, since if both he and his partner were found to be carriers of the same disease, they would have a high risk of having an affected child (25% with each pregnancy).

I had just finished counseling him about the diseases we would be testing him for and the reproductive options for carrier couples, when he glanced at the BRCAcommunity study brochure that was lying on my desk. The cover reads:  BRCA testing is right for some…Is it right for you?  That was when he asked his question that many others also have asked since. “Can you also test me for BRCA while I am here already?”

Testing for BRCA is not like testing for Tay-Sachs, but I understand why the question was asked. (Note: for the remainder of this blog, I will use Tay-Sachs as the example of preconception testing, but testing is recommended for a much larger panel of diseases). We talk about how certain genetic conditions are more common in Ashkenazim.  We talk about Tay-Sachs disease and BRCA-related Hereditary Breast and Ovarian Cancer (HBOC) syndrome as examples of this all the time. And we advocate for genetic testing before contemplating a pregnancy, so why not kill two birds with one stone and do it all at once?

The answer is complex and related to the differences in the conditions themselves. The first difference has to do with the nature of the diseases; that is, Tay-Sachs and the other common diseases for which we test preconception are diseases that occur in infants or young children. Some of the diseases on our panel end in early death and others progress throughout one’s lifetime, but they are all chronic diseases that burden the affected individual for the long-run. HBOC is in a different league since it is adult-onset. We don’t see BRCA-related cancers in infants or young children.

Furthermore, if a child has inherited both non working copies of the genes that cause Tay-Sachs, that child will have Tay-Sachs. However, if someone has inherited a genetic mutation in BRCA that causes HBOC, that person is at increased risk to develop a related cancer, but it is not a guarantee.

The reason we recommend carrier screening for Tay-Sachs and diseases in that category is so that couples could be made aware of their risks to have a child with a debilitating disease before they conceive or early in a pregnancy, and may make reproductive and life decisions based on their risks. Does information about adult-onset diseases—that are not even guaranteed to happen—fall into the ‘want to know before contemplating a pregnancy’ bucket?

The second difference between Tay-Sachs and HBOC has to do with inheritance patterns. Tay-Sachs is transmitted in an autosomal recessive manner; that is, carriers are not at risk of developing the disease themselves, but their offspring are at risk if both parents are carriers. HBOC is an autosomal dominant syndrome, which means that if someone carries the mutation, he or she is at increased risk to develop the disease (not just the offspring). In addition, each of his or her kids have a 50% chance of inheriting the mutation and its associated cancer risks—regardless of the other parent’s carrier status. When going to learn about your potential children’s health in a preconception genetics appointment, would you also be ready to learn about your own health risks?

My two points about the differences between Tay-Sachs and HBOC are pretty strong, and because of them, I do not know of any reproductive genetics practices offering BRCA testing in the preconception realm. The one argument that supports preconception BRCA testing is that if a couple knew that one of its members carries a mutation, this couple might consider doing pre-implantation genetic diagnosis (PGD) to select against BRCA-mutation carrying embryos when planning their families.

So while PGD is an option for BRCA carriers, we generally do not offer preconception screening for BRCA to all those of Ashkenazi descent (an exception could be someone who has a known mutation in a close family member, or someone with a strong family history of cancer). The counseling for BRCA is very different than it is for Tay-Sachs, and genetics professionals do not believe that a session about preconception carrier testing is the appropriate environment to bring it up. I wonder if our patients would agree.

Making Histories: Tree of Life, A BRCA Conversation

Guest Blogger, Sherry Kabran, writes about her amazing new project, Tree of Life, A BRCA Conversation http://www.treeoflifebrca.org:

tree of lifeWhile in mourning, some try to cope with their emotions and loss by writing journals, going to support groups, blogging, running races, attending daily minyans, even starting cancer oriented organizations.  The women in my family found their own ways to accept the loss of Carolyn Raizes Davis, mother and sister, but together we created Tree of Life:  a BRCA Conversation guide for Passover, Shabbat and Rosh Chodesh.

Each guide helps Jews of Ashkenazi descent understand basic facts about hereditary cancer risks from BReast CAncer gene mutations.  The highlighted message is that every family should create a family medical tree, look for red flags and consider genetic testing, if appropriate.  The guides provide a Jewish setting in which to start a serious conversation that might save the 1 in 40 Jews of Ashkenazi descent, who unknowingly has a BRCA gene mutation.

This family project was our suggestion to FORCE (Facing Our Risk of Cancer Empowered) to further reach out to the Jewish community with a teaching tool.  How could we not try to help?  Carolyn passionately believed in teaching the community about BRCA gene mutation risks and worked closely with The Methodist Hospital doctors in Houston, Texas, to develop an educational program.  Her legacy was EDUCATE anyone who will listen!

My younger sister, Francine, and I decided Passover was an ideal time to have a multi-generational discussion about gathering medical histories.  We know about oranges and coffee beans on the Seder plate.  How about a tree branch, to represent the importance of medical family trees?  Each guide provides: an introduction to start the conversation, a BRCA branch symbol of family trees, a choice of videos, a medical history form to gather health information, Debbie Friedman’s Mi Sheberach prayer and suggestions for next steps.

Of course I googled “Passover & family histories” and found Chani’s post suggesting families do just that, at the Seder table!  Her blog is incredibly informative and thought provoking.  Plus, she told me to take the conversation guide idea and run with it.  Thank you, Chani, for your encouragement.

The Davis/Raizes/Kabran family hopes readers will explore the guides (http://www.treeoflifebrca.org) and decide to use one during family gatherings.  Please tell us about the experience. Also, help us save lives by sharing the website on Facebook and forwarding the free downloadable guides to family members, friends and community leaders (Jewish organizations are beginning to offer BRCA educational programs).  Your suggestions for use of the guides and ways to publicize would be greatly appreciated.

Thank you,

Sherry Kabran:   treeoflifebrca@gmail.com

Update Your Genetic Testing! A Different Perspective

to do listLast year I blogged about the importance of updating your preconception carrier screening between pregnancies since new diseases are added to the testing panels pretty often.  This is a topic I am very passionate about and always tell my patients, friends, and relatives. More recently, I started to think about the idea of “updating genetic testing” from a different perspective.

When I take family histories in a cancer genetic counseling session, my patients often tell me that a relative had cancer years ago, but he/she did genetic testing and was negative (ie- had normal results). While this information may be helpful, I often tell them that if the genetic testing was done a while ago, they may want to get more testing done since there are now better testing options in the realm of cancer genetics than there were years ago.

“Updating” in the preconception realm generally refers to adding on additional diseases to the panel, and in the cancer and pediatric realms, it can refer to repeating a test that was already done, using a different testing method with a better detection rate, or pursuing genetic testing–for different genes–that was not available at the time.

Let’s look at individuals who have strong personal or family histories of breast/ovarian cancer (“high risk”) as an example.  In 1996, ‘sequencing’ (scanning the entire gene) for both BRCA1 and BRCA2 became commercially available through Myriad Genetics, the only BRCA testing lab at the time.  At that time, we had already identified that there are three mutations in these genes that are more common among Ashkenazi Jews. Since about 95% of Ashkenazis who have a BRCA mutation will have one of these three mutations, genetic counselors would order ‘multisite’ testing (genetic testing for those three mutations only) for their Ashkenazi high risk patients. As research has advanced, new techniques with higher detection rates were introduced to the market. In 2002, Myriad added a new test to identify 5 large rearrangements in the BRCA genes and in 2006, they added ‘BART’ testing, which looks for large deletions and duplications throughout both genes. With each new technology applied to genetic testing in the same gene, the detection rate has gotten higher. Since then, genetics professionals have recommended that high risk Ashkenazi Jews who test negative for the three common Ashkenazi mutations complete additional genetic testing in the BRCA1 and BRCA2 genes– full sequencing and BART testing. Multisite testing is still used as the first step (and sometimes only step) of testing Ashkenazis, since it is likely that if one has a mutation, it is one of those three. And to take it a step further, high risk individuals who test negative for all known BRCA mutations are being offered genetic testing for panels of many genes known to be associated with breast/ovarian cancer.

So when my patient with a very strong family history of ovarian cancer tells me that her affected sister had BRCA testing in 2001 and had normal results, I feel a slight sense of relief, but I still have concerns that there is a hereditary component to the family’s cancer. I recommend that they come back in for more comprehensive testing, if possible. The same holds true for pediatric or adult patients with genetic concerns that have not been identified.

Just as family histories are dynamic, and people may develop medical issues over time, so too, the availability and breadth of genetic testing is not static and is expanding at a fast pace. I now tell most of my patients to check back with us in a year or two, because more information or more testing may be available at that time. While it may be hard to keep up, a consultation with a genetic counselor who is knowledgeable in the field might be very helpful to you and your family.  You can find a genetic counselor near you at www.nsgc.org.

Raising Awareness –a Key to Prevention

KEEP CALMA genetic counselor colleague of mine just posted the singing group One Republic’s new music video , “I Lived”. The video features 15 year old Bryan, who gives us a glimpse into living with a common genetic disease, cystic fibrosis (CF).  The lyrics to the song are an inspiration, as are the interludes of Brian speaking about his dreams for his (short) life (The life expectancy for an individual with CF is about 36 years).  I will admit that I cried when I watched it and bet some of you will too. I started to think about how amazing it is that a band with such a huge following (the video has 12,608,608 views on YouTube!) was able to make an impact on the CF world with a statement that is 5 minutes and 39 seconds.

The purpose of this blog is not to talk about CF, but I will give a brief synopsis of the condition. CF is one of the diseases that we talk about in every reproductive genetics appointment at our clinic at Montefiore.  Like SMA and fragile X, CF carrier testing is offered to all women who are pregnant or considering a pregnancy. Carriers of CF have no symptoms of the disease, but if their partners are also carriers of CF, then there is a 25% risk with each pregnancy that the child will be affected. Unlike many of the specifically Ashkenazi diseases we screen for, CF is pan-ethnic. It is estimated that 30,000 children and adults in the US and 70,000 worldwide are affected with CF. The Cystic Fibrosis Foundation has done phenomenal work in the realm of education, advocacy, and fundraising for research initiatives, and you can visit their website to learn more about the disease.

I think about all of the recent publicity for different diseases and it amazes me…This past summer’s Ice Bucket Challenge to raise awareness for ALS, Angelina Jolie’s op-ed in The New York Times disclosing her BRCA carrier status, Catherine Zeta Jones’s disclosure that she is being treated for bipolar disease, Movember’s amusing mustache-growing competitions during the month of November to raise awareness for men’s health issues, and the Cincinnati Bengal’s  recent high-profile fundraising campaign to sell Devon Still’s jersey for pediatric cancer research (his 4 year old daughter is battling cancer).  What an impact these movements have made on the world!

Young Bryan from the One Republic video, and all of these public figures, are doing a service to us by telling their stories.  Awareness and education about these diseases are not only essential to empower people to try to take preventative measures for themselves and their children, but it also plays a vital role in increasing understanding about diseases and their impact. Genetic (and non-genetic) diseases should not be taboo to discuss. So please, if you feel comfortable, share your stories. You don’t need celebrity status to do so.

Egg Freezing-Now a Job Perk?

8886048502_44698ab556_zBig companies, such as Apple and Facebook, have recently announced that their female employees would be offered free “egg freezing.” The idea behind the process of egg freezing, or oocyte cryopreservation, is that a woman who is not ready to have children may freeze her eggs and later re-implant them in her uterus via an in vitro-fertilization process when she is ready for children.  Freezing eggs puts a halt on their biological activity and, literally, ‘freezes them in time.’

A woman’s eggs stay with her from pre-birth until menopause, so just like we get older, so do our eggs. Our eggs don’t gray and wrinkle, but they certainly age; and the aging process may cause serious issues in the chromosomes of the eggs. You have probably heard that the risk for Down syndrome (a condition caused by having an extra chromosome 21) is increased in older moms. That is because their older eggs are more prone to having errors in meiosis, the process of chromosome division.

The cost of egg freezing nears $10,000 for every round, plus $500 or more annually for storage. It seems like these large companies are finding that losing their valuable employees to maternity leave and family time is detrimental, and that women should feel encouraged to plan out the lives they want if they want to get set on their careers first. Not surprisingly, there has been a lot of buzz around these announcements from Apple and Facebook, ranging from full support to skepticism of using egg freezing for non-medical purposes (one particular piece I enjoyed reading was an op-ed in the New York Times from a few weeks ago).

While career building may be a valid motive to freeze eggs, there are other reasons a woman may consider this process. I have been asked whether egg freezing would be a good option from some women who have not yet met the man with whom they want to build a family, in case they do not get a chance to start their family until they are older. There are also medical reasons a woman may decide to freeze her eggs. For example, women who undergo cancer treatment which may be toxic to their eggs may decide to preserve their eggs before they begin their therapy.  In addition, women facing certain genetic conditions that lead to premature failure of ovarian function may also choose to freeze their eggs–some examples include those with Turner syndrome or fragile X premutation carriers. In addition, women who are BRCA carriers may opt to remove their ovaries to reduce their risk of developing breast and ovarian cancer, but may not be ready to have children. These women could freeze their eggs for a later pregnancy.

Of course I also need to mention that older women who are having babies (whether or not the eggs have been cryopreserved) tend to have older spouses. Because of the large number of cell divisions in spermatogenesis, the process of sperm development, the mutation rate in certain genes is higher in men than women, and increases with age. So we are finding that certain genetic diseases are more common in babies with older dads as well. Such diseases include certain forms of dwarfism, some types of craniofacial disorders, and some more complex diseases such as autism, schizophrenia and cancers.

The American Society for Reproductive Medicine does not recommend the use of egg freezing for purposes of delaying childbearing, since data on safety, the efficacy, and the cost-effectiveness, and emotional risks are insufficient. They say that “marketing this technology for the purpose of deferring childbearing may give women false hope and encourage women to delay childbearing.” Nevertheless, egg freezing for career reasons is a reality. But should it be?

Genetic Testing at Birth-Is it too Early?

 

UntitledI recently saw a 50-something year old man for a cancer genetic counseling session. When we got to the concept that mutations in the BRCA genes may increase someone’s risk to develop breast and/or ovarian cancer, he was amazed. He said to me, “If the technology exists for someone to know his or her genetic risk to develop cancer, and there may be something to do to reduce these risks, wouldn’t it make sense to learn this information when someone is young?”

I was pleased to hear this question since it proved to me that he was really paying attention, and although he didn’t realize it, he touched on an issue which is very timely in the world of genetics and ethics.  The issue of whole genome sequencing (reading through all of someone’s genes to look for variation) is a hot topic in genetics. Currently, the reasons we might order any genetic testing are if there is an underlying medical issue for the individual, a family history of an issue, or if someone is from an ethnic group that has known founder mutations for particular diseases. When we do this sort of testing, we are looking for relevant mutations in one or more genes or chromosomes.

But recently, scientists have introduced the notion of testing the entire genome of all newborns-even those who are seemingly healthy. (Note: I am not talking about the Newborn Screening panel—AKA “heel stick test” or “PKU test”—which is mandatory in the United States, and tests for about 30-55 diseases, depending on the state).  And to make things sound even more exciting, the first baby to ever have his genome sequenced prenatally was born last month in California!

Back in November 2012, Nicole blogged about her discomfort of whole genome testing, as opposed to targeting the genetic testing to the medical issue at hand.  When we do whole genome sequencing, we are going to learn about that person’s traits, carrier status, predispositions to childhood and adult-onset disease,  and we may even diagnose a disease, possibly presymptomatically (ie- before the person even starts exhibiting symptoms). Some might think that all this information is great, since it’s better to know now than to be surprised when it happens.

Others believe that this type of testing for newborns is unethical. Here are a couple of reasons why:

1-The genes belong to the child, not the parents. Shouldn’t it be up to that child to make this decision?

2- Say we learn that the child is genetically predisposed to having Parkinson’s disease. This most likely will not happen for another 50 or so years, and it may never happen at all.  Does he want to be that person who is just waiting to get sick? This may cause anxiety, stigma, and may change the way his family and friends perceives him.

3- If someone learns from a young age that he has a genetic predisposition to a condition, he may ignore the other (non-genetic) risk factors. For example, let’s say someone learns that he has a genetic variant that leads to a high chance of developing diabetes. He may not try to eat healthy foods or exercise or go for checkups because he believes that his genes alone will determine his risk for diabetes. This is what we call “genetic determinism.”

I told my patient that he did not realize that he had opened up a can of worms and that we would need a whole new session just to discuss his question. But he definitely got me thinking.

 

Genetics and Athletics

heart basketballLast week while my husband and I watched the NBA draft, we were touched to see 20 year old Isaiah Austin receive a ceremonial pick by the NBA. Austin is a star center for Baylor’s basketball team and has been projected to be a first round pick in the next NBA draft.  When he went for his routine physical, his electrocardiogram was abnormal, and Austin was sent for a more comprehensive cardiac workup. Soon after, he was diagnosed with the genetic condition known as Marfan syndrome and was advised by his doctors to quit playing competitive basketball.

At 7’1”, Austin’s height makes him an asset to any basketball team, but his height also is telling of his condition. Marfan syndrome is a connective tissue disorder.  Because connective tissue is found throughout the body, Marfan syndrome can affect many different parts of the body, such as the heart, blood vessels, bones, joints, and eyes. The classic “Marfanoid habitus” is someone who is very tall and thin, with long fingers, flexible joints, scoliosis, and a chest that sinks in. Some features of Marfan features, such as aortic enlargement (expansion of the main blood vessel that carries blood away from the heart to the rest of the body), can be life-threatening. So while some signs of Marfan are easy to see, some affected individuals may have the disease and not even know. Those affected individuals are at highest risk to have sudden cardiac death (SCD), since they might not be seeing their doctors or reducing their risks of aortic dissection or lung collapse.

Each year, SCD claims more than 300,000 lives in the United States. Up to 10% of cases of sudden cardiac death in general, and 25% of cases involving a family history, are thought to have a hereditary basis. Aside from Marfan, there are other conditions which can include SCD—some of these conditions include Long QT, Brugada syndrome and hypertrophic cardiomyopathy. Most inherited arrhythmia conditions such as those mentioned have an autosomal dominant inheritance pattern. If someone has it, there is a 50% chance he or she will pass it on to each child.  For many of the SCD diseases, genetic testing can help establish a diagnosis and may serve as a tool to screen family members.  Medications, medical surveillance, and reducing physical activity can save lives. As with Austin, knowing your risk before something devastating happens is key.

Austin was tested for Marfan because he had an abnormal screening test, but most athletes do not engage in genetic testing.  Sports-related genetic testing is not widely used, but is available. While many professional sports organizations have shown interest in having players screened for conditions such as sickle cell disease and hypertrophic cardiomyopathy, GINA issues arise and players’ genetic information is no longer legally accessible to their employers.  Recently, more than a dozen companies have started  to offer sports-related personal genomics tests and services. The “DNAthlete: Athletic Profile” provides consumers with genetic information related to endurance, muscle mass and strength, and grip strength. While the clinical utility of this information is up for debate, many athletes may want this information so they can integrate it into their training regimens.

“I have a whole life ahead of me,” Austin said. “I’m not going to sit here and I’m not going to sulk about not being able to play basketball anymore, because I can still be involved with the game somehow or some way.”

When asked what’s next, Austin responded “Everything.”  And that is exactly why he was the NBA’s most valuable draft pick.

When Bio Isn’t So Boring

My personal and professional worlds recently collided when I sat with my 9th grade son, Brian, to review for his upcoming Biology exam. The subject was the reproductive system, the stages of pregnancy, and fertility. The chapter ended with infertility issues and in-vitro fertilization (IVF), which allowed me to take his Biology unit one step further and explain to him the amazing technology known as “pre-implantation genetic diagnosis (PGD),” a topic on which my Program for Jewish Genetic Health colleagues frequently educate the Jewish community. At first, probably like most teenagers, he didn’t want to learn any more than what he HAD to know for his exam. But I was able to pique his interest by giving him a real life example of the miracle of PGD.

When Brian was 12 years old, one of his Little League teammates, Cody, had a younger brother named Jack who had Familial Dysautonomia (FD), one of the Jewish genetic diseases. Jack was like the team mascot, always there to cheer on Cody and run around the bases after many games. Cody also had two, twin toddler siblings often running around on the sidelines. While Brian knew that something wasn’t quite right with Jack, he was unaware that a modern day technology – PGD – enabled Cody’s mom to subsequently give birth to healthy twins.

So while reviewing infertility and IVF – and harking back to his previous Genetics unit – I was able to bring his Biology unit to life. I first showed him my MyJewishGeneticHealth.com “work” video of Cody’s mom, talking about how the miracle of PGD enabled her to give birth to two healthy twins and know they would not be born with FD. I then signed in to our full MyJewishGeneticHealth.com lesson to show him real video of how PGD is performed…plucking cells from 3-day old harvested embryos and testing them for disease, before implanting the healthy embryos into the womb. It was a real “Whoa, that’s cool!” moment for him, to see video of this technology at work, and to understand the peace of mind it gave to Cody’s mom and dad when they gave birth to their twins.

It’s often a challenge to make your child understand why the material they are studying in class is worthwhile. By showing Brian how modern day science can truly make an impact and prevent heartache in people’s lives, I was able to interest him in learning more than he needed to know for his exam.

Updating Your Carrier Screening

update carrier screening croppedWhen I was at a recent sisterhood event at my synagogue, a friend of mine approached me to ask if she should “do her genetic testing again” since she and her husband were first tested in 2007 and have not been tested since. I answered with an emphatic “YES!” I appreciated that she knew to even ask this question, but our conversation got me thinking. Do other people know that new diseases are regularly being added to the Ashkenazi  Jewish panel?

The best time to get screened is well before a pregnancy. Since the 1980s when Tay-Sachs testing was introduced to the Ashkenazi Jewish world, there has been much progress in the realm of genetic testing. Currently, we screen for about 18 diseases that are common in this population. And testing for Sephardi and Mizrahi Jews as well as Jews of mixed ancestry has become more commonplace. But someone who was tested in 2001, for example, and was negative, is not “in the clear” since many more diseases have been added to the panel since then.

Many people ask me, “If I am already married, why should I bother updating my testing? It will only make me more anxious as I continue having children.” My response is that I’d rather find out that you are both carriers of the same genetic disorder by doing a blood test, rather than finding out after you have an affected child. There are other options besides for stopping childbearing, rolling the dice with each pregnancy, and breaking up! Other family planning options include testing the fetus early in the pregnancy, using an egg or sperm donor, and adoption. In-vitro fertilization with pre-implantation genetic diagnosis (PGD) is another great alternative for couples who want to know their child’s genetic status before it is even in-utero. By doing genetic testing this early on, a couple will avoid getting pregnant with an affected embryo and will circumvent any ethical or issues related to Jewish law that may arise.  Robin’s Story, a short public service announcement on MyJewishGeneticHealth.com, will open your eyes as to the importance of updating your screening and learning your options. And be sure to register to watch Dr. Lieman’s longer webinar about PGD and Chani’s lesson about preconception carrier screening!

Finally, while testing for diseases that are common in specific populations is currently recommended by professional genetics groups, there are labs who are now offering screening for many more diseases. These expanded carrier screening panels claim to be “one size fits all” and are marketed to all ethnicities, but a negative result on a broader screening does not fully eliminate the risk of having a child affected with one of the tested disorders, it only reduces the risk. Furthermore, expanded carrier screening does not cover all diseases that could affect offspring.

I wish I could go into every synagogue, preschool, sisterhood, and other places where women in their childbearing years hang out to remind them to update their carrier screening! But since that is impossible, please take the time to mention it to your family and friends and help me spread the message. Let’s avoid heartache together!

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