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May 16, 2005anne said in reply to Carol from CO...
Life at the Top in America Isn't Just Better, It's Longer
By JANNY SCOTT
- Jean G. Miele's heart attack happened on a sidewalk in Midtown Manhattan last May. He was walking back to work along Third Avenue with two colleagues after a several-hundred-dollar sushi lunch. There was the distant rumble of heartburn, the ominous tingle of perspiration. Then Mr. Miele, an architect, collapsed onto a concrete planter in a cold sweat.
- Will L. Wilson's heart attack came four days earlier in the bedroom of his brownstone in Bedford-Stuyvesant in Brooklyn. He had been regaling his fiancée with the details of an all-you-can-eat dinner he was beginning to regret. Mr. Wilson, a Consolidated Edison office worker, was feeling a little bloated. He flopped onto the bed. Then came a searing sensation, like a hot iron deep inside his chest.
- Ewa Rynczak Gora's first signs of trouble came in her rented room in the noisy shadow of the Brooklyn-Queens Expressway. It was the Fourth of July. Ms. Gora, a Polish-born housekeeper, was playing bridge. Suddenly she was sweating, stifling an urge to vomit. She told her husband not to call an ambulance; it would cost too much. Instead, she tried a home remedy: salt water, a double dose of hypertension pills and a glass of vodka.
Architect, utility worker, maid: heart attack is the great leveler, and in those first fearful moments, three New Yorkers with little in common faced a single, common threat. But in the months that followed, their experiences diverged. Social class - that elusive combination of income, education, occupation and wealth - played a powerful role in Mr. Miele's, Mr. Wilson's and Ms. Gora's struggles to recover.
Class informed everything from the circumstances of their heart attacks to the emergency care each received, the households they returned to and the jobs they hoped to resume. It shaped their understanding of their illness, the support they got from their families, their relationships with their doctors. It helped define their ability to change their lives and shaped their odds of getting better.
Class is a potent force in health and longevity in the United States. The more education and income people have, the less likely they are to have and die of heart disease, strokes, diabetes and many types of cancer. Upper-middle-class Americans live longer and in better health than middle-class Americans, who live longer and better than those at the bottom. And the gaps are widening, say people who have researched social factors in health....
June 19, 2011
Hugh Pickens writes "Gerontologists say 'aging in place' vastly improves the quality of life for seniors, and is a lot cheaper for society than group homes and institutions. The trick is to do so without jeopardizing the health and safety of older people, which is why 480 people are taking part in pilot programs in Portland, Oregon that outfit homes with technology so elderly people can be monitored for illness or infirmity. With the first wave of baby boomers turning 65 this year, corporations such as Intel see lucrative new business opportunities tending to a generation of people accustomed to doing things their own way. As part of a test, Dorothy Rutherford's two-bedroom condominium has been outfitted with an array of electronic monitoring gear that might eventually find its way to retail shelves. Motion sensors along hallways and ceilings record her gait and walking speed. A monitor on her back door observes when she leaves the house, and another one on the refrigerator keeps tabs on how often she's eating. A special bed laced with sensors can assess breathing patterns, heart rate and general sleep quality, a pill box fitted with electronic switches records when medication is taken, and a Wii video game system has been rejiggered so that players stand on a platform that measures their weight and balance. But there is the downside, as some experts on the aging population worry that making it easier for elderly people to stay in their homes could reduce the incentive for children to visit or could create a false sense that technology can foresee every problem and address every need."
Whuffo: I see the golden liningvlm (69642)
GE and Intel are lining up for a big suck on the elder care teat. It's nice that some monitor in some remote location will beep when they have a problem - but by the time they get the message, and get a medical team on site (from Wyoming?) it's going to be a bit on the "too late" side.
Letting the old folks live out their lives and die at home is a good thing; they'll enjoy a better quality of life and they won't be stuck with crippling medical bills. But I'm having a little trouble figuring out how a few dozen kilobucks worth of GE and Intel stuff is going to do anything to improve their lives.
The only winners here are the corporations - with luck, they can get federal healthcare funds to pay for all of it (at properly inflated prices).they'll enjoy a better quality of lifeLuckyo (1726890)
Oddly enough I only see physical health gadgets. No gadgets for mental health at all. You'd think they could have made even a simple token gesture attempt. Perhaps the stereotypical video conferencing solution, or digital picture frames of the grand kids, or something, something at all.they won't be stuck with crippling medical bills.
These corporations are not doing work out of the goodness of their heart, in the style of from each according to their ability and to each according to their need. The whole point of this technological exercise is a DIFFERENT group will be delivering the crippling medical bills, instead of the current group. Is this group any better? Eh, probably, more or less. The good news they aren't getting the negative personal interactions and experiences of a nursing home for awhile longer. The bad news is their only personal interaction now seems to be a Wii-based bathroom scale.Most of the elderly have a problem with their kids not visiting them nearly enough, and their mental health suffering greatly from loneliness as a result. I would know, I worked in elder care on a summer job and being the only guy I actually didn't have to wash/take care of person hygiene of anyone in spite of that being one of the main tasks.
Know why? Because I was the only young guy who applied and got the job, and my main job consisted of just going to old men's places and talking to them or doing some heavy lifting for them. Frankly, I think that's also what put a lot of thing in perspective for me back then - I was a young kid, and seeing just how lonely these people were on a personal level taught me to really appreciate my own life. Because when it was pretty damn obvious that for those months I worked there, the person's high point of the day was my 15-minute visit to deliver him the newspaper and food, and chat him up to see how things are makes you really appreciate how good your own life is even in the angsty late teen period.
Sometimes I think that maybe a mandatory service for all youth a la conscription to work at a elderly care for a few months or a year would be a good thing, and not just for the system.
cpu6502 (1960974) Re:I see the golden liningOne problem with our society is that we build our relationships around work.
Once we retire, the work friendships disappear, and people are left with nothing.
Back during the agrarian age, our friendships were mostly local neighbors who were always present right upto death.
The United States has fallen behind other nations, failing to provide affordable health care to its citizens. Americans spend $477 billion a year MORE on health care than other advanced countries. So why do we pay so much compared to other wealthy nations? This infographic is part two in a two part series which dissects the state of our health care system and presents some alarming numbers.
Mar 23, 2011
Driving home from school today, I listened to a Fresh Air interview from two months ago with Atul Gawande, by now perhaps the most famous doctor in the policy intelligentsia. The interview was based on a New Yorker article discussing how some doctors and even some health care payor organizations are trying to reduce health care costs for the most expensive people while improving outcomes. In Camden, New Jersey, one doctor found that one percent of people generate thirty percent of health care costs.
One refrain you heard incessantly during the health care reform debate was that we have high health care costs because of overconsumption and we have overconsumption because people don't bear a high enough share of their marginal health care costs, so the solution is to increase copays and deductibles. This is what Economics 101 would tell you: people respond to incentives. But Gawande discussed one large company that tried this year after year, but only saw their costs going up. The problem was that while most members responded to the higher copays and kept their costs more or less steady, the 5 percent of members who generated 60 percent of the costs behaved differently. Or, rather, they also reduced consumption (of doctor's visits and prescription medications), but as a result they often had catastrophic outcomes. These were people with heart disease on cholesterol-lowering medications, and when they went off their medications they ended up in the hospital with heart attacks and then with congestive heart failure.
If incentives worked on this level, we should have solved the problem already. Employers all want to bring health care costs down, so if any insurer could bring health care costs down they would have a competitive advantage, and so insurers should be trying to bring health care costs down. But it's not working. One explanation is that insurers don't have enough market power compared to providers (like large hospital chains); I believe Uwe Reinhardt has explained the situation this way.
Another way of looking at the problem is to note that there is no one who is trying to brings costs down directly. Sure, insurers try to do it, but they do it through the types of monetary incentives that economists love: higher copays, lower payments for various procedures, etc. But that's not actually what most companies do when they have a cost problem. If you run an auto company and it's costing too much to build a car, you don't lower the transfer price that you pay to that factory and let incentives solve the problem. You go and figure out what the problem is and you engineer a solution, whether by redesigning the manufacturing process, reengineering the product to use cheaper parts, negotiating lower wage costs, negotiating lower input costs, or something else. That's how you solve most problems in the business world - not by tweaking some clever incentive scheme.
This is a high-level analogy for what Gawande is talking about: doctors and health care organizations identifying their most expensive patients or members, figuring out what's wrong with them, and getting them the right treatments. In the few examples that Gawande discusses, it results in cost reductions on the order of 20 percent with better outcomes. It seems that for the people who consume the most health care dollars, you can save money simply by focusing on giving them better care - because right now their big problems are things like coverage gaps that prevent them from getting basic care, not being on the right medications, and ending up in the emergency room for catastrophic problems. Maybe for most people you would not save money simply by providing better care, but for the few people who consume most of the system's resources, maybe you would save money. The problem is that with few exceptions, no one is trying to do that. That's what we need an incentive for.
The incentives worked they just did not produce the desired outcome –people stayed away, but the incentives encouraged people to avoid obtaining preventitive healthcare. They stayed out a certain health care "market" (which it manifestly is not since larges swaths of participants cannot freely enter or exit) –the one that those interested in containing cost should actually nurture. I think if you redesign incentives to encourage "wellness" –if you quit smoking your employer gives you a bonus since it will lower company costs –you might see a better cost containment strategy in the making.
The problem isn't with the form of the incentives, but with the people. Three of the people in the New Yorker article, for example, had serious health problems of their own making.
- One was an asthmatic with a crack habit. Smoking crack would result in severe asthma attacks requiring emergency care. She had no interest in quitting crack.
- Another was a obese diabetic who repeatedly refused her doctors' advice for diet and exercise until after her third heart attack.
- A third patient had many chronic and severe conditions stemming from his obesity (over 500lbs) coupled with alcohol and cocaine abuse.
If the medical consequences aren't incentive enough for these individuals to change their habits, neither increasing copays nor promising to reduce premiums will make a difference.
At the risk of sounding callous, I wonder about the morality of forcing everyone else to pay for the choices of those who refuse to take responsibility for themselves and repeatedly end up in the hospital for choices they actively and make.
The problem of cost is much larger than providing better care for those with poorer health. We need a system that penalizes physicians for providing un-needed care.
This article on the cost of health care in McAllen, Tx. finds that the cost is frequently driven by the profit motive of the health care providers. In order to reduce costs all of the drivers of cost should be considered and dealt with.
"McAllen has another distinction, too: it is one of the most expensive health-care markets in the country. Only Miami-which has much higher labor and living costs-spends more per person on health care"
If there is an element of chance, then most folks will gamble and think they can save money and not suffer because they skimped on their 'ounce of prevention' - instead later requiring a 'pound of cure.'
Just another example of things that the market does badly, along with protecting the environment, or ensuring a level-playing field, or maximizing societal happiness.
This last assertion is a big one, and so let me elaborate. Globalization allows companies to reduce production costs by outsourcing the peon jobs, thereby putting domestic workers out of business, but at the top, the profits get big (for a while, until the middle class consumer class disappears), and so the upper management reward themselves with huge bonuses. But overall, the gains at the top have come at the expense of the middle class, and many more middle class workers are now job-less (or underemployed, perhaps working as a greeter at WalMart). Mergers do the same thing. They render jobless a whole array of now redundant management positions, and those at the top of the pyramid do better. Big companies also get to the point that they can afford to lobby as individuals, and so legislative and regulatory capture becomes an issue as well. In short, unregulated markets result in income disparity, societal polarization, and non-competitive market behavior. This is the hard truth the 'small government is beautiful' folks refuse to admit, instead working dutifully to evoke fond and distant memories of Dutch and his dewy eyes as he communicated to us how much he cared about our future.
Government of the rich, by the rich, for the rich. Banana republic 101.
The problem is that there is a good chance–especially as we get older–that ALL of us will be in the one percent who consume the 30% or so of medical costs at some point.
Ok, I just re-read the original Gawande article in the New Yorker. While James' post is clearly a "half empty" the article is closer to 7/8 full.
"An experiment in Atlantic City conducted by the Casino Workers' Union and AtlantiCare Medical Center.
After twelve months in the program … their emergency-room visits and hospital admissions were reduced by more than forty per cent. Surgical procedures were down by a quarter. The patients were also markedly healthier. Among five hundred and three patients with high blood pressure, only two were in poor control. Patients with high cholesterol had, on average, a fifty-point drop in their levels. A stunning sixty-three per cent of smokers with heart and lung disease quit smoking. In surveys, service and quality ratings were high."
"But was the program saving money?"
" … the Atlantic City workers in Fernandopulle's program experienced a twenty-five-per-cent drop in costs."
"A recent Medicare demonstration program, given substantial additional resources under the new health-care-reform law, offers medical institutions an extra monthly payment to finance the coördination of care for their most chronically expensive beneficiaries. If total costs fall more than five per cent compared with those of a matched set of control patients, the program allows institutions to keep part of the savings. If costs fail to decline, the institutions have to return the monthly payments."
"Several hospitals took the deal when the program was offered, in 2006. One was the Massachusetts General Hospital, in Boston."
"Three years later, hospital stays and trips to the emergency room have dropped more than fifteen per cent. The hospital hit its five-per-cent cost-reduction target."
When the incentives are right and applied properly, they work. There's lots of good news in Gawande's piece. And its the good news part we need to focus on.
The idea that we have a "system" of health care is the greatest misnomer. What we have is a collection of independent, profit oriented actors (specialists) working on aspects of person's health care without any responsibility for the overall outcome. It should not be surprising that a small percentage of people account for a large percentage of health care costs. Nobody is responsible for integrating the total care structure for patients. There are exceptions, but the general economic and organizational structure of the current "system" results in a fragmented approach to health delivery.
High health care costs are not, primarily, the result of overconsumption. We pay more for health care than any other nation, in many cases by a factor of 2 or more, and have worse outcomes (ranked 37 or somethng like that). If we want to contain costs and improve outcomes we will need to fundamentally rethink the health care system.
That means challenging Big Pharma (twice as much spent on marketing than R&D), Big Hospital chains, health insurance companies that increase revenues and net every time health care costs rise since they pass the cost through in the form of premiums, oversupply and overuse of technology and, in many cases, overpaid doctors who profit from self-referral, Big Pharma incentives, etc.
Until we begin to address these issues – even study them – we aren't going to contain health care costs. And we won't decrease the costs by passing more of them along to consumers. The problem is overcharge, not over use.
Patient incentives don't work. Yes, this is basic.
Nonetheless, you are doing a good service to explain it, for those that aren't aware yet.
I wish you would attract more of the readers that matter - those designing plans - by titling your post correctly: Patient Incentives Don't Work.
Here's the next step though:
Incentives can help a lot when they act as an information input for those that actually do the choosing/deciding in health care - doctors.
After months of writing and thinking on this, I wrote a blog post about incentives that would work:
Two points to consider:
1. Often, the wrong entity in the process is given the ecomomic incentives. Instead of providers/organizations/hospitals being given extra money when they reach benchmarks, how about we directly incentivise patients? How about a payment or discount when a patient quits smoking or is compliant with his or her medication?
2. If health plans or organizations spend extra money up front to give high level of care and service to patients right from the start of their illness, the argument is that the organization saves money in the long run. The business problem with this idea is that patients often change insurance plans and medical groups on an annual basis. The change is precipitated by employers choosing the least expensive offering. By the time economic savings on care is seen, the patient has changed plans two or three or more times…
Jan 25, 2011
Dr. "Ishabaka" shares some tips on staying fit ands maintaining motivation.
Becoming fit and eating healthy food are the best preventative tools we have within our own control. One reason fitness and healthy cooking play such big parts on this site is that it is increasingly unlikely that the Medicare/Sickcare system will be around long enough to cure us of all our lifestyle-related diseases.
In other words, we'll be on our own: we will need what I call radical self-reliance. Rather than hoping we can acquire enough gold or quatloos to fund costly healthcare for ourselves and our families in the future, the better alternative is to avoid as many chronic lifestyle-related illnesses as possible via fitness and healthy diet (i.e. eating real food only).
Dr. "Ishabaka" is middle-aged and fit. In an email "conversation," we discussed the challenges of motivation, and the good doctor agreed to summarize his own experiences and what he's observed in others.
The principles of fitness and nutrition apply to people of all ages, hence the inclusive title of the entry.
Here are Dr. "Ishabaka's" suggestions:Today is January 5th. I hadn't exercised for 11 days, and gained 6 pounds over the holidays. Last night I decided it was finally time to do something, and set my alarm so I'd wake up early and be able to go to the gym. When the alarm went off this am I was SO tempted to turn it off and go back to sleep. I made my way to the gym - it was leg day, my least favorite exercise day. I felt like crap. My strength was down about 25%. Twice I felt like throwing up, and once like passing out. I managed to finish. How I did so is the subject of this article.
I joined my gym four years ago, as a result of a New Year's resolution to get in better shape. Little did I know....
Every January, the gym is packed. I often cannot use the equipment I want - someone else is using it. This lasts 4-8 weeks, then things go back to normal - which means most people who joined in the New Year GAVE UP! Why? Because they COULD NOT STAY MOTIVATED. I see this as THE number one issue in fitness in middle age.
There are some lucky people who truly love to exercise. I presume none of them are reading this, so I'll dispense with them and address the rest of us, for whom exercise is mostly a chore.
I think a major stumbling block is the concept of "getting in shape". It's sounds like a project you can accomplish and finish. I think it's better to plan on "staying in better shape" - it's a lifelong process. If you stop at any point - no matter how "in shape" you were - well, just take a look at this picture:
Again, to repeat - it's a lifelong process. Also, the concept of "getting in shape" suggests that one is going to end up looking like a fitness model - which is impossible for 99% of the population. If you're thirty pounds overweight, and can only run one mile at 12 minutes per mile, losing twenty pounds and running two miles at 11 minutes per mile is definitely " getting in better shape".
Another concept I find helpful is to compare overeating, eating unhealthy food, and lack of exercise to an addiction, such as alcoholism. There is no "cure". Improvement is possible in almost every case - but almost certainly, there WILL be relapses. Relapses are often very demoralizing, and quite difficult to overcome. Plan on them occurring.
Here are some strategies and tips I have found useful:
1. Try as many activities as you can before deciding what to concentrate on. Try and choose at least one aerobic, and one strength activity - your body needs both.
2. Get a workout partner. This has helped me more than anything. If possible, choose someone who is fitter/more knowledgeable, and push each other. It's a lot harder to turn off the alarm clock if you've made an appointment to go running/biking/to the gym with your workout partner in the morning. A partner is particularly helpful when you relapse - that's why A.A. has sponsors.
3. Join a class or a group. For some reason, women tend to do this and men don't. Again, you will have a pre-determined time when you are supposed to exercise, and instructors and classmates to urge you on.
4. Set goals for yourself. Write them down. Post them where you can see them (I tape mine to the bathroom mirror). I strongly believe in setting ACHIEVABLE goals. If you write down "lose 80 pounds", it's just too daunting, and you'll likely give up. Instead, write down "lose 6 pounds in 2 months". Unless you give up, you will almost certainly achieve this, and possibly lose even more than 6 pounds, which sets up what I like to call a "virtuous circle", the opposite of a "vicious circle". In a virtuous circle, success encourages further success.
5. Increase the intensity of your exercise in small increments. If you can curl a 20 pound dumbell ten times when you start, don't expect to be able to curl a 50 pound dumbell in a month. Your initial goal should be to curl the twenty pound dumbell eleven times. The same goes for walking/running/biking/swimming speed and distance. Realize that if you curl that same 20 pound dumbell ten times for two years - you aren't going to make any progress. I call this "going through the motions", and it's surprising how many people at my gym do this. I think it's a form of self delusion: "Well, I worked out at the gym today", when the person really didn't push their body at all.
One big hurdle many face - myself included - is what's called "delayed onset muscle soreness" or DOMS. This is muscle pain that comes on a while after exercise. In my thirties, I found it maxed out the day after. Now it's two days after. I wonder if it will be three days after in my sixties? It definitely helps to ease into exercising - the worst thing you can do is go crazy your first session, and wind up bed ridden for a week. Nonsteroidal anti-inflammatory drugs such as ibuprofen (Motrin, Advil) don't seem to help. Stretching may or may not help, depending on who you read. One thing I have found - it sounds counter-intuitive - is that it's best to resume exercising before all the pain is gone. If I wait till I'm 100% pain free, the cycle seems to just repeat itself. If I resume when the pain is mild - moderate, I seem to adjust, although I'm always a little achy somewhere.
6. Enter a competition. This gives you a goal AND a time period in which to get in shape. I suggest a 5 kilometer (3.2 mile) run. They are held all the time just about everywhere. Even if you can't run non-stop for 5 kilometers, you can do what's called "run-walking" - run until you are tired, walk until you recuperate, then run some more. I guarantee you won't win your first 5k (and probably will never win one), but you won't be last - and you will get a cool finisher's t-shirt to wear, that will make people think you are really in shape!
7. Spend the minimum amount of money possible, at least in the beginning. Sign up for a one or two month trial membership at a gym if you've never belonged to one - you don't know if you'll like it or not. Don't buy a $3,000 triathlon bicycle for your first triathlon - use your ten year old mountain bike. You're goal is just to finish.
If triathlons turn out to be your thing, you can always buy the expensive bike later. The attics, basements, and second hand shops of America a littered with expensive exercise equipment people bought and abandoned.
The ONLY exception I would make is shoes. I'm assuming people reading this are middle aged, and although we may say "Fifty is the new thirty", our bodies don't agree - they have fifty years of wear and tear on them.
Slamming fifty year old feet (likely carrying excess poundage) in poorly cushioned, poorly supporting shoes, on concrete, over and over again, is likely to cause injury. Injury is perhaps the single most demoralizing thing that can affect a fitness program. For that reason, I suggest consulting a doctor first if you have, or are at risk of serious health problems, starting gradually, progressing incrementally, and NOT neglecting flexibility and balance.
The number one cause for admission to nursing homes in the U.S. is falls, and maintaining good balance and flexibility will minimize the likelihood of a fall happening - and - if one does happen - the likelihood of serious injury.
8. Finally, when I'm really demoralized, sometimes I'll tell myself "Just do some damn thing for a little while". Whether it be a thirty minute walk, one mile run, or half an hour at the gym, it's better than nothing, and seems to have a surprisingly positive effect on getting me out of a funk.
Thank you, Doctor, for sharing your experiences and tips. Here are a few links and comments of my own on the subject.
Stretching is good. Flexibility improves health, and stretching helps with back pain and other conditions. It's also a form of exercise, and the warmup provided by stretching often gets you in the mood for further exercise. Yoga, tai chi and chi gung also improve balance, which tends to degrade with age.
Learning how to fall is good. I know Dr. "Ishabaka" is also a martial arts practitioner, and one of the most valuable things I have learned in martial arts is how to fall: lower your center of gravity, tuck your head down and roll.
Muscle mass is a factor in cardiovascular health. Studies have shown that the quantity of muscle one builds and retains is a predictive factor in overall health. Walking is good, but keeping upper-body muscles requires more than walking.
Avoid temptation by keeping your kitchen free of junk food and packaged snacks. If it's not around, you won't crave it as much. "You don't miss what you no longer want."
Push yourself gently, don't hurt yourself. Wake up slowly, stretch, warm up, know your limits and push up to them but not past: common sense, to be sure. Patience and perseverence go hand in hand.
Self-discipline is good. I have a number of "bad genes" as the men in our family are prone to heart disease, high cholesterol and high blood pressure. So it takes more work on my part to counteract these negatives. At 57, discipline is required.
Avoid "sacrifice," seek positives. Americans are trained to worship instant gratification and ease. As a result, many see eschewing ice cream etc. as "painful sacrifices" and arduous exercise (which results in so little immediate gain) as equally painful and unpleasant.
I don't think of what I'm setting aside; I "reward" myself if I fulfill my fitness goals. So there's no "sacrifice," only "rewards."
Some exercise is better than none. If I'm really tired, then I'll walk 2 KM, about 20 minutes. My goals are higher, but some days I can't muster the energy. But doing some exercise makes me feel good.
Work burns calories. Gardening, housework, etc. burns a lot of calories. But those activities don't offer cardio-workouts; they're not enough, but they can certainly reduce weight.
Work up to higher levels slowly and comfortably. I once read the story of a 60-ish woman who was out of shape. She started walking one block a day, then slowly added distance. Eventually she tried jogging a block. Slowly, she ran a bit longer as it felt comfortable. After some time, she was running several miles and enjoying it.
The form doesn't matter, the routine matters. It doesn't matter if it's yoga, tai chi, chi gung, walking, biking, swimming, etc., it's making it part of your routine so you miss it if you don't get to do it.
Cross-training is good, especially as you age. Like many others, I see cross-training as common-sense. I don't run more than once or twice a week, but bike every day and walk some distance a few times a week. Ditto pushups and some other muscle-building stuff.
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