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  • By Lois W. Stern, Editor-at-Large, Makemeheal.com

    A little over a year ago I wrote an article about the tragic death of Donda West, mother of the celebrity rapper, Kanye West, following plastic surgery. In the aftermath of Kanye’s rude mishap with Taylor Swift at the VMA Awards , I thought I would revisit his mom’s tragic story.

    Donda and Kanye, Plastic Surgery

    Why tragic? After doing some research on her case, I concluded that a significant factor in her death was due to poor medical judgment. Well, here we go again, some more bad news following plastic surgery. But this time, due diligence may avert the supreme tragedy of another life lost.

    While investigating the Donda West tragedy, I had called both the ABPS (American Board of Plastic Surgery) and the ABMS (American Board of Medical Specialties) to inquire about the board certification of Donda West’s surgeon, Dr. Jan Adams. I learned two alarming facts. Dr. Jan Adams was not listed as a board certified plastic surgeon. Furthermore the only physician on record with the ABMS bearing the name Dr. Jan Thatcher Adams was board certified in Family Medicine – not plastic surgery.

    Dr. Jan Adams, Plastic Surgery I concluded that if Donda West had only made those phone calls prior to selecting her surgeon, she might have selected differently. She might even be with us today.

    Donda’s autopsy results yielded no physical findings (such as a heart attack or blood clot) to explain why she went into cardiac arrest. According to Barry L. Friedberg M.D., a board certified, globally recognized leader in the field of office-based anesthesia, it was unlikely that either the length or extent of West’s surgeries caused her death. “More likely, it was the manner in which the surgery was performed; i.e. under general anesthesia which does not reliably produce pre-emptive analgesia and, therefore, often necessitates postop narcotics to manage pain. If West had sleep apnea as a pre-existing condition, even average doses of narcotics could easily prove fatal,” claims Dr. Barry Friedberg.

    We will never know for sure what killed Donda West. But we do know that sound medical judgment comes only with quality training followed by lots of experience putting that training to practice.

    Kanye West and Donda West, Plastic Surgery

    On June 13th, 2009, the Hartford Courant ran a story about Dr. Efraim Gomez-Zapata, a name currently in the news for allegedly practicing plastic surgery without proper credentials. (According to the Hartford Courant, Dr. Efraim Gomez-Zapata is credentialed as a family practice physician, but because his name is not listed with the Connecticut State Medical Board, I was unable to verify this information.). His medical license has been suspended by this same board based on charges that he violated medical standards by performing plastic surgery without appropriate qualifications or standards to protect patient safety. The allegations of the Connecticut Department of Public Health against Dr. Efraim Gomez-Zapata include administering anesthesia and performing plastic surgery on patients without the proper license or qualifications and failing to keep proper records or have the appropriate staff, equipment, office setup and hospital privileges required in case of complications. In two patient cases cited where complications did occur, one woman had a seizure after Gomez-Zapata administered a combination of painkillers, anti-anxiety medication and a local anesthesia; while a second went into respiratory arrest after Gomez-Zapata gave her a spinal anesthesia.

    What simple steps can the rest of us take to avoid fates similar to those of Donda West or the unfortunate patients treated by Dr. Gomez-Zapata? I like to think of the word TEE (short for Training, Experience and Expertise) as a handy acronym to help me remember how to investigate the credentials of any prospective surgeon.

    TRAINING: Know that ANY board certified physician in any field of medicine can legally perform plastic surgery and call himself a cosmetic surgeon.
    DO YOUR HOMEWORK. Be sure you have selected a surgeon board certified
    in the area that relates to your surgical needs or desires.

    EXPERIENCE: You can check out the history of any prospective surgeon by calling the medical records department of the state where he practices. Visit http://www.floridamalpractice.com/linksotherstatebds.htm for the telephone number of the medical records department of the state where your surgery will take place.

    I do not know how many cosmetic surgeries either Dr. Jan Adams or Dr. Efraim Gomez-Zapata has performed. But I do know that their surgical histories send up some immediate red flags. According to medical records from the state of California, in 2001 two malpractice lawsuits were filed against Adams, ending in payouts of close to half a million dollars. Prior to the Donda West tragedy, three new, unsettled medical malpractice lawsuits were pending against this same doctor. As for Dr. Gomez-Zapata’s record, we do know that one of his patients experienced seizures during surgery and a second went into respiratory arrest. These are enough red flags to alert us to quickly do an about face and walk away from either of these offices.

    Another way to assess the adequacy of a surgeon’s experience is to inquire about the number of procedures of a particular type he performs each year and how long he has been performing them. Ask to speak with some of his patients and try to meet with them in person to assess the surgeon’s work.

    EXPERTISE:
    Ask your surgeon where he has hospital privileges and place a phone call to that hospital to inquire if he has privileges to perform the exact procedures you are considering. This step is essential, even if your surgery is to take place in an outside surgical facility. Why? The chief of plastic surgery assesses the experience and skill of the surgeon before granting him privileges for any surgical procedure. Surgeons are often granted privileges for some procedures while having privileges for others withheld, based on their experience and expertise. If a surgeon skirts this issue or tells you it isn’t necessary for him to have hospital privileges since surgery will take place in an outside
    facility, turn around and walk!

    Dr. Jan Adams, Plastic Surgery

    It is important to learn how to separate the sound from the noise. Donda West’s surgeon, Dr. Jan Adams had appeared on numerous national TV shows, including Oprah, CNN, Entertainment Tonight, and Discovery Health, to name a few, as a plastic surgery ‘expert’. I congratulate his PR agent for doing a phenomenal job. But great hype does not a great surgeon make. Surgical expertise does not come from making TV appearances.

    Statistically, cosmetic surgery procedures have a strong safety record, but you need to heed some cautions. In a study evaluating the safety of accredited office based surgical facilities, only 1 death occurred in 58,810 surgical procedures, but there is one important caveat to that study that should not be overlooked: All of these procedures were performed in office surgery facilities accredited by the AAAASF.

    While in the process of writing my first book, I had the privilege of interviewing Dr. Keyes, the lead surgeon of the above study. He explained that each surgical facility accredited by the AAAASF mandates that a) the doctor be board certified in the medical specialty recommended for that procedure and b) that the doctor has been granted privileges to perform those same procedures in the hospitals with which he is affiliated. Again, remember to do your homework.

    Her
    e are just a few of the life saving questions you should ask before engaging a surgeon

    Question Mark

    Do you have hospital privileges to perform the procedures I am considering? If so, where?

    What you should do next: Call the hospital(s) to inquire.

    What is your board certification?

    What you should do next: Contact the American Board of Medical Specialties (Internet: www.abms.org/ Phone:1-847-9091) Consider surgeons with board certification in: plastic surgery, ophthalmology, otolaryngology, dermatology. Here is where Experience and Expertise come into play.

    Is the facility where your surgery will take place an accredited facility?

    What you should do next: Ask by whom? You are in good hands if accredited by the AAAASF or AAAHC for ambulatory facilities or the JCAHO for hospital facilities.

    Who will administer my anesthesia?

    What you should do next: Find out if this person is a board certified anesthesiologist? Understand that the training of a board certified anesthesiologist is far more comprehensive than that of a nurse anesthetist. In determining the extent of your anesthesia needs, consider the extent of your surgery, your physical condition and age.

    You need to consider the risks and rewards to your surgery. Here are some additional questions to ask your surgeon:

    What are the risks to my surgical procedures?

    Do you consider me a good candidate for the surgeries I am requesting?

    Do I have any medical condition, health habits, etc. that we need to consider?

    I am ever mindful of the words of Dr. Rohrich, former president of the ASAPS and a member of their Innovative Procedures Committee: Most women spend more time selecting a pair of shoes than selecting a plastic surgeon. You can take back your shoes, but you can’t take your face or your life back.

    Lois Stern, Plastic Surgery

    Lois is the author of Sex, Lies and Cosmetic Surgery and Tick Tock, Stop the Clock. She also has developed a special Support Tool DVD for Professional office use – a practical communication tool to help surgeons personalize their services while communicating with their patients. Check out Lois’s website at: www.sexliesandcosmeticsurgery.com.

    Coast To Coast, Patty Kovacs, Lois W. Stern

    Lois and Patty Kovacs are the co-founders of Coast2Coast – Eye on Beauty Newsletter.


    Tags: , , , , , ,

    Comments

    16 Comments so far

    1. Barry L. Friedberg, M.D. on September 29, 2009 6:37 pm

      I congratulate Dr. Stern on growing beyond the usual rhetoric of only a board certified ‘plastic’ surgeon should do plastic surgery & recognizing the legitimate work done by board certified ophthalmologists, otolaryngologists (ENTs), dermatologists. This is quite remarkable and long overdue.

      I am also proud of her recognition of the greater training of the medical practice of anesthesia (anesthesiologists) over that of the nursing practice (nurse anesthetists). By that I do not in any way mean to demean or belittle the satisfactory service my nurse colleagues have provided. Again, one cannot confuse service with educational level.

      The death of Donde West was addressed by 2 press releases posted on my web site during the month her death occurred. A reporter supplied me with a copy of her autopsy to review and provide comment.

      Yes, it is true that her right coronary artery had some narrowing; however, it was an entirely incidental finding! There was NO evidence of ischemia or loss of oxygenated blood supply to the heart muscle below this narrowed area. Her death was completely unrelated to the narrowing of her right coronary artery.

      Donde West was found not breathing, most likely because she had been taking narcotic pain medication.
      She had needed this medication because the general anesthesia she received did not provide preemptive analgesia.

      Although the toxicology screen did not reveal abnormally high levels of opiate in her blood, the levels were high enough in someone who may have had enough of a tendency to sleep apnea to push her over the edge when she needed opiate medication for postoperative pain relief.

      Had Donde West received propofol ketamine (PK) anesthesia, she would have also gotten preemptive analgesia, avoided the need for postoperative opioid pain medication, and very likely would still be alive.

      Ch 1. of Anesthesia in Cosmetic Surgery is available frre from http://www.CosmeticSurgeryAnesthesia.com. Tables 1-6 through 1-9 contain detailed instruction on how to provide PK anesthesia.

    2. Grant Van Meter on October 12, 2009 1:08 pm

      I would like to say that whoever wrote the section of the article under “Who will administer my anesthesia?” is way off base and obviously has a poor understanding of what kind of training a Nurse Anesthetists gets. As a CRNA, I have worked alongside anesthesiologists who have made some extremely unwise decisions leading to poor outcomes for patients. I have known multiple Nurse Anesthetists who would put a board certified anesthesiologist to shame in regards to both knowledge and skill. In most large institutions, it’s the Nurse Anesthetist who provides the actual hands on patient care and the anesthesiologist who sits in the preoperative area doing preoperative interviews all day. On the other hand, I’ve worked with many anesthesiologists who were exceptional providers. Nurse Anesthetists have been providing all types of anesthesia for approximately 150 years in every surgical setting and were the first anesthesia provider profession in the United States. Your statement is obviously based on biased opinion and not on fact.

    3. Michael MacKinnon on October 12, 2009 2:32 pm

      It is disappointing to see statements by the author suggesting that there are some outcome difference between a board certified anesthesiologist and a nurse anesthetist (CRNA). Though there have been many studies done over the years, none has proven that an anesthesiologist is any safer or has better outcomes than a nurse anesthetist. Both are excellent providers but one is not better than the other. Statements like this are misleading to the public and entirely without evidence. It should be removed.

    4. John Canady on October 13, 2009 2:10 pm

      As a CRNA with 12 years of independent-practice anesthesia experience, including 18 months in Iraq and 4 months in Central America, I too found the comments about “the greater training of the medical practice of anesthesia (anesthesiologists) over that of the nursing practice (nurse anesthetists)” to be misleading. I have always provided anesthesia personally; based on my own training, experience, and clinical judgment. I have never simply “assisted the anesthesiologist.” Further, the vast majority of my practice has been in settings with no anesthesiologist available at all; with no difference in patient safety, satisfaction, or quality outcomes.

      In my practice, I frequently field questions from patients about what the difference is between anesthesiologists and CRNAs. I typically answer, with a chuckle, “about $150,000 per year” then follow with “actually, about 6 months training.” Is that the “greater training” that these comments refer too? The length of the average CRNA training program is 30 months while anesthesiology residency is 36 months. Six months more time as a student of anesthesia that the average CRNA. That’s it.

      It’s tiresome hearing how anesthesiologists are better prepared to provide anesthesia because they “complete 4 years of residency and 4 years of medical school.” The first year of that “residency” is actually an internship, not anesthesia training. Four years of traditional or osteopathic medical school followed by a one-year internship is the same training that a dermatologist, allergist, or psychiatrist completes. And no, I’m not attempting to demean the training of those medical specialties. My point is this: Would you want your allergist performing your anesthesia, just because he or she went to medical school?

      After completing our 30 months of training, CRNAs provide hands-on anesthesia every day, compared to the typical anesthesiologist who provides hands-on anesthesia care less than one day per week in some settings. The CRNA’s daily hands-on delivery of anesthesia care quickly erases any benefit, either imagined or real, that the anesthesiologist’s 6 months of additional training might have initially offered.

      The first formal CRNA training program was established a full 50 years before the first anesthesiology residency training program, which didn’t occur until thousands of general medical officers returned home from World War II looking for work. Anesthesia was a recognized specialty of nursing for half a century before the first newly-minted anesthesiologists began claiming anesthesia as the practice of medicine and began their ongoing attempts to subvert CRNA practice.

      I find it fascinating that so many physicians today chose to spend 3 years training to practice in a nursing specialty then spend so much time and energy constantly trying to undermine our history, professionalism, and clinical contributions to safe surgical and anesthesia care. You would think they would be more grateful for the opportunity we CRNAs have provided them.

    5. Barry Friedberg, M.D. on October 14, 2009 6:19 am

      The negative comments posted by my CRNA colleagues were as predictable as they were lamentable. These comments did a disservice to their credible anesthesia service to which I referred to in my previous post.

      The only thing missing was the threat of litigation if the truth about ‘a medical education not being equivalent to a nursing education’ was not removed from the article.

      In my Curriculum Vitae, I was very proud to note that Naglehout’s 2001 CRNA textbook was among the first anesthesia textbooks to cite my propofol ketamine iv sedation technique.

      Anesthesiology is the practice of medicine limited to anesthesia and is recognized by degree and state licensure nationally. Anesthesiology is also recognized by American Board of Medical Specialty (ABMS). Nurse anesthesia is not recognized as such.

      A 4 year medical education is not equivalent to a 3 year nursing education. An MD is not equivalent to an RN.

      One cannot compare the depth of understanding of disease pathology and its impact on the physiology of one’s patients acquired in medical school to that acquired in nursing school.

      One cannot compare the act of administering anesthetic agents (the nursing practice of anesthesia) to the preoperative assessment of patients, the design of an anesthetic plan and its implementation (or supervision in the anesthesia care team) and postoperative pain management (anesthesiology – the medical practice of anesthesia).

      There are about 43,000 anesthesiologists and 40,000 CRNAs to care for nearly 300,000,000 Americans.
      The huge geographic disparity of provider distribution in the US means that many states have opted out of ‘Medicare supervision rule’ out of shear necessity to provide anesthesia services. That necessity has still not caused these same states to grant equivalency to the RN degree with the MD degree.

      All of this having been said, I also say, let’s get on with taking care of our fellow Americans. Be proud of who you are and what you do. But, please, stop confusing your service with your education. That serves no one, especially yourselves, well.

    6. Stephen J. Blanchard, CRNA, DNAP on October 14, 2009 11:54 am

      As a CRNA who has practiced in every model of care from solo anesthesia provider to the anesthesia care model, it saddens me to continually read disparaging remarks from either anesthesiologists or nurse anesthetists. The fact is, there has never been a study demonstrating that anesthesia care is any better or safer whether delivered by an anesthesiologists or by a nurse anesthetists – the anesthesiologists know this and the nurse anesthetists know this. Any inference otherwise is purely anecdotal and without foundation. As legitimate scientists and professionals evidenced based practice and paradigms should guide our judgement and our practice – not petty differences.

      I personally do not agree with the comments that carelessly insinuate a lesser quality of anesthesia care when delivered by a CRNA. In fact, there are millions of patients, whose anesthetic was managed by a CRNA, that can concretely refute this baseless allegation. Too many patients falsely assume that their anesthesia care provider was an anesthesiologists when in fact it was more than likely it was a CRNA. Statistics show that more than 65% of anesthetics are actually performed by CRNAs.

      I ask you this – when you make flight reservations, do you ask how the pilot has been trained? Have you ever refused to get on an airplane because of the method in which the pilot actually became a pilot? Probably not. Did you know that the principles and concepts of Anesthesia Crisis Resource Management, a disciplined practice concept taught to both providers, is actually based on the same training that pilots and crew have been receiving for decades – the same principle that Chesley Sullenberger III used to land his plane in the Hudson. And yet, we never ask how that pilot was originally trained.

      Simply put, anesthesia is delivered safely and effectively by two different anesthesia providers – MD anesthesiologists or nurse anesthetists. Our journey through training, like pilots, is a little different, but the destination is the same. We read the same books, are held to the same standard of care, use the same drugs, the same anesthesia machines, measure the same physiologic parameters, apply the same pathophysiologic considerations and, ultimately, deliver the exact same quality of anesthesia regardless of procedure or setting. Lets stick to the facts and the truth – does anyone really think that CRNAs would still be delivering over half the anesthetics in this country, for almost 150 years, if patients lives were in danger?

    7. Grant Van Meter on October 19, 2009 9:32 pm

      I would like to state that Barry Friedberg’s use of this article regarding Donda West’s death for his shameless self-promotion is lamentable. His comments did a disservice to the credibility of anesthesiologists. This self proclaimed “PK anesthesia guru” has not only utilized this space to market his book and website. He has also misrepresented the education of the Nurse Anesthetists. That 4 year medical school degree didn’t teach him anything about how to provide anesthesia and can’t be compared to the 3 year anesthesia education of the Nurse Anesthetist. He knows very well that the education of a Nurse Anesthetist during their anesthesia training is easily equivalent to his residency training where he actually learned how to provide anesthesia. There isn’t a single textbook he learned out of that a nurse anesthetist hasn’t been taught from. Anesthesiologists don’t have some “special knowledge” regarding anesthesia that Nurse Anesthetists don’t have. In addition, what about the evidence? Studies have proven that patients outcomes are no different when care is provided by a Nurse Anesthetist compared to an Anesthesiologist. The author ought to read the Pine Study, the Bechtoldt study, Forest study, Minnesota Department of Health study, or the National Academy of Sciences study. All show no difference in care…only a difference in cost. That’s why I’m proud to be a CRNA.

      In addition, ketamine’s properties of analgesia and lack of respiratory depression make it a great adjunct to anesthesia in appropriate situations. However, it’s no amazing miracle drug. It has many adverse side effects such as hallucinations/nightmares, salivation, nausea, vomiting, double vision, and nystagmus. In addition, it can induce hypertension and tachycardia, which in light of Donda West’s coronary artery disease and potential risk of myocardial infarct, wouldn’t necessarily made it the anesthetic of choice as you proclaim. Yes, you did publish a study regarding the use of propofol and ketamine that is referenced in multiple texts…congratulations…you’re the man. I hope you get a lot of acknowledement from that amazing study. I use propofol and ketamine together all the time and from now on I’ll think to myself….thank you Barry Friedberg.

    8. Barry L. Friedberg, M.D. on November 16, 2009 2:17 pm

      “It’s what you know for sure that ain’t so that gets you into trouble.” -Samuel Clemmons aka Mark Twain

      Nurse van Meter’s knowledge about the side effects of ketamine might have improved by reading some of my published work, beginning with my first PK publication:

      Friedberg BL: Hypnotic doses of propofol block ketamine induced hallucinations. Plast Reconstr Surg 91:196,1993.

      All of the items listed given by our nurse commentator as ketamine side effects are only correct with FORMER paradigms of ketamine use, i.e. ketamine given as a solo anesthetic or in the presence of inadequate levels of hypnosis.

      Using propofol and ketamine ‘together’ is the paradigm published by Guit in Anaesthesia in 1991, but NOT what I advocate.

      I advocate & use propofol and ketamine ‘sequentially’ (not mixed together).

      This sequential paradigm was originally published as diazepam (Valium) and ketamine in Aesthetic Plastic Surgery by Vinnik in 1981. I always take care to cite this paper and honor Vinnik having taught me about ketamine.

      In 17 years and in more than 5,000 patients, NONE of the side effects described in nurse van Meter’s comment have occurred.

      As to the issue of nausea and vomiting:

      Friedberg BL: Propofol-ketamine technique, dissociative anesthesia for office surgery: a five year review of 1,264 cases. Aesthetic Plastic Surgery 23:70-74,1999… reported a 0.6% PONV rate, the lowest published nausea and vomiting (PONV) rate in the literature.

      It is even more significant because those patients had 3 of 4 Apfel defined risks for PONV; i.e. they were at high risk for PONV.

      According to current guidelines, these patients SHOULD have received 2 or 3 anti-nausea medications to prevent PONV.

      The 0.6% PONV rate was achieved in this high risk group WITHOUT the use of anti-nausea medications.

      Dr. Christian Apfel is one of, maybe, 20 anesthesiologists to have ever published their work in the New England Journal of Medicine.

      Apfel is the unquestioned world authority on PONV & wrote the first ever PONV chapter in Miller’s Anesthesia, 7th edition, 2010.

      For the past 25 years, Miller’s ‘Anesthesia’ has been the most respected (& cited) textbook in the field.

      In his chapter in Miller’s ‘Anesthesia,’ Apfel also cites my 1999 paper (above) as a positive example of what happens to PONV when both stinky gases (inhalational anesthetics) and narcotics (opioids) are avoided.

      Regarding the avoidable death of Donde West:

      If nurse van Meter had read Donde West’s autopsy (as I did), he would have noted there was NO evidence of heart muscle damage ‘downstream’ or below her incidental finding of right coronary artery lesion.

      Her occult heart disease had nothing whatsoever to do with her death. Aside from that detail, myocardial infarctions (heart attacks) are not a cause for patients to stop breathing unless they precipitate death. However, there is no evidence for any myocardial infarction in Dr. West’s autopsy.

      I believe nurse van Meter should be proud of who he is and what he does. But, please, kindly stop confusing your laudable service with your education. No amount of ‘alchemy’ can transform an RN into an MD. Persisting in this effort with erroneous bloviating serves no one, especially the noble service of your fellow nurse anesthetists, well.

    9. Grant Van Meter on December 8, 2009 2:30 pm

      I would like to state that Barry Friedberg’s use of this article regarding Donda West’s death for his shameless self-promotion is lamentable. His comments did a disservice to the credibility of anesthesiologists. This self proclaimed “PK anesthesia guru” has not only utilized this space to market his book and website. He has also misrepresented the education of the Nurse Anesthetists. That 4 year medical school degree didn’t teach him anything about how to provide anesthesia and can’t be compared to the 3 year anesthesia education of the Nurse Anesthetist. He knows very well that the education of a Nurse Anesthetist during their anesthesia training is easily equivalent to his residency training where he actually learned how to provide anesthesia. There isn’t a single textbook he learned out of that a nurse anesthetist hasn’t been taught from. Anesthesiologists don’t have some “special knowledge” regarding anesthesia that Nurse Anesthetists don’t have. In addition, what about the evidence? Studies have proven that patients outcomes are no different when care is provided by a Nurse Anesthetist compared to an Anesthesiologist. The author ought to read the Pine Study, the Bechtoldt study, Forest study, Minnesota Department of Health study, or the National Academy of Sciences study. All show no difference in care…only a difference in cost. That’s why I’m proud to be a CRNA.

      In addition, ketamine’s properties of analgesia and lack of respiratory depression make it a great adjunct to anesthesia in appropriate situations. However, it’s no amazing miracle drug. It has many adverse side effects such as hallucinations/nightmares, salivation, nausea, vomiting, double vision, and nystagmus. In addition, it can induce hypertension and tachycardia, which in light of Donda West’s coronary artery disease and potential risk of myocardial infarct, wouldn’t necessarily made it the anesthetic of choice as you proclaim. Yes, you did publish a study regarding the use of propofol and ketamine that is referenced in multiple texts…congratulations…you’re the man. I hope you get a lot of acknowledement from that amazing study. I use propofol and ketamine together all the time and from now on I’ll think to myself….thank you Barry Friedberg.

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    16. KayCee on October 7, 2012 3:27 pm

      I find the portion of the article referencing anesthesiology to be inane. How many times does a patient interview with an anesthesioglogist, answer the entire battery of profile questions, establish a repore only to find on the day of surgery – A COMPLETELY DIFFERENT PERSON. For the majority of us these tips are futile. We have no such control. It is alarming that even the celebrated have such tragic results.

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