Barbui T, 3d ed. Blood. 2003;78:174–94.... 2. Therapeutic options for essential thrombocythemia and polycythemia vera. In 2016, the World Health Organization published new criteria for diagnosing PV. Worsley A, Gilbert HS. All rights Reserved. Jackson N, Burt D, Crocker J, Boughton B. Because PV is a rare condition, it has been difficult to assemble patients for well-designed, randomized controlled trials with long- term follow-up. Your doctor may examine your bone marrow even though the test isn't needed to diagnose PV. Interferon alpha in the treatment of polycythemia vera. Consultation with a hematologist is recommended. Erythromelalgia is rare, occurring in approximately 3 percent of patients with PV. 24. Therapeutic recommendations in polycythemia vera based on Polycythemia Vera Study Group protocols. Diagnosis and Management of Polycythemia Vera: Proceedings from a Multidisciplinary Roundtable. JAMA. Patients treated with phlebotomy alone had the same rate of cancer as patients in the control groups.2,14,20, The nonalkylating myelosuppressive agent hydroxyurea is widely used in the treatment of PV, because it is less leukemogenic.22 PVSG data have established this agent to be an effective bone marrow suppressant. Diagnosis and treatment of polycythemia vera and possible future study designs of the PVSG. Mayo Clin Proc. Overview. Pearson TC. Mayo Clin Proc 2003;78:184. 20. Adapted with permission from Tefferi A. Polycythemia vera: a comprehensive review and clinical recommendations. Other conditions associated with aquagenic pruritus include myeloproliferative neoplasms or myelodysplastic syndromes, hypereosinophilic syndrome, and … Ferrant A, Michiels JJ. Polycythemia vera is the most common of the myeloproliferative neoplasms; its incidence in the United States is estimated to be 1.9/100,000, with incidence increasing with age. Interferon alpha-2b: a new treatment for polycythemia vera. Therapeutic recommendations for polycythemia vera. The U.S. Food and Drug Administration (FDA) has approved a test called ipsogen JAK2 RGQ PCR Kit to detect mutations affecting the Janus Tyrosine Kinase 2 (JAK2) gene. Polycythemia vera should be suspected in patients with elevated hemoglobin or hematocrit levels, splenomegaly, or portal venous thrombosis. … 2001;115:619–21. Get Permissions, Access the latest issue of American Family Physician. a Bone marrow biopsy may not be required in cases with … Kutti J, Michiels JJ, Download or order The Leukemia & Lymphoma Society’s free booklet. The diagnosis and management of polycythemia vera in the era since the Polycythemia Vera Study Group: a survey of American Society of Hematology members’ practice patterns. The test also checks for the presence of immature (blast) cells in the blood. Juvonen E. Spivak JL. BRIAN J. STUART, LT, MC, USNR, is serving with the Second Medical Battalion, Second Flight Support Group, Group Aid Station, at Camp Lejune, N.C. Polycythemia vera: diagnosis and treatment 2002. Wasserman LR. Contact Evaluation of diagnostic criteria in polycythemia vera. 3d ed. Physicians may refer patients to a specialty laboratory for this study. ... all criteria for CMML are present, and the eosinophil count in the peripheral blood is more than 1.5 × 10 9. 6. Alter BP. With the establishment of polymerase chain reaction (PCR)based methods for detecting the JAK2 V617F mutation, this may become the first molecular diagnostic marker for PV, similar to BCR/ABL for chronic myelogenous leukemia (CML). Diagnosis is made using criteria developed by the Polycythemia Vera Study Group; major criteria include elevated red blood cell mass, normal oxygen saturation, and palpable splenomegaly. Alter BP. The PVSG and Gruppo Italiano Studio Policitemia (GISP) are two prospective trials that have unearthed a therapeutic dilemma regarding the two basic treatment approaches—phlebotomy alone and phlebotomy plus myelosuppressive agents. Finazzi G. Weinberg RS, 58th ed. In: Kjeldsberg CR. These include electrolyes, fats, proteins, glucose (sugar) and enzymes. An algorithm summarizing the evaluation and management of PV is presented in Figure 1. Br J Haemat. If the antibody is present at a high level, it may also suggest that there is a higher risk of severe joint damage. Sources of funding: none reported. Semin Thromb Hemost. Bone marrow biopsy showing proliferation mainly of the megakaryocyte lineage with increased numbers of enlarged, mature megakaryocytes with hyperlobulated nuclei. Choose a single article, issue, or full-access subscription. Chlorambucil, busulfan, and pipobroman, all alkylating agents, have fallen out of favor because of concerns about rates of iatrogenic leukemia.19 The agent 32P remains in use with supplemental phlebotomy and has a reported median survival similar to that of phlebotomy alone—10.9 years according to PVSG data14 and 11.8 years according to GISP.20 The myelosuppressive drugs such as 32P had an initial advantage over phlebotomy alone regarding thrombosis rates during the first three years of treatment. Diehn F, Pearson TC, Polycythaemia vera (PV) is a clonal haematological malignancy characterised by pronounced symptoms, including fatigue, pruritus and symptomatic splenomegaly, along with an increased risk of thrombosis and the potential for evolution to myelofibrosis and secondary acute myeloid leukemia [].. PV is classified under myeloproliferative neoplasms (MPNs), according to the … Diagnosing polycythemia vera: a paradigm shift. Haematologica. 1997;102:14–20. Michiels JJ, et al. Fruchtman SM, Wasserman LR. Berger U, The use of myelosuppressive agents such as radioactive phosphorus (32P), chlorambucil (Leukeran), busulfan (Myleran), pipobroman (Vercyte), and hydroxyurea (Hydrea) in conjunction with phlebotomy has been studied. Guest editor of the series is Anthony J. Viera, LCDR, MC, USNR, Deep Venous Thrombosis and Pulmonary Embolism, Health Care Screening for Men Who Have Sex with Men. There's no cure for PV, and without treatment, it can cause serious complications such … Bernard M, The resultant hyperviscosity of the blood predisposes such patients to thrombosis. Am Health Drug Benefits . Sackett DL. Physician’s desk reference. Finally, EEC growth is based on the ability of erythroid cells from peripheral blood and bone marrow samples in PV to grow in vitro without the addition of EPO.12,13 This unique finding, along with serum EPO levels, forms the basis for a new diagnostic approach,5 but has the disadvantages of expense and limited availability.10. Gilbert HS. Michiels JJ, A patient with secondary polycythemia should have a return to normal red blood cell counts once the primary problem is successfully treated. Semin Hematol. Patients can present with arterial or venous vascular occlusive events, microvascular disturbances or, occasionally, haemorrhage. Comparisons may be useful for a differential diagnosis. Greenwood Village, Colo.: Thomson Micromedex, 2004. Copyright © 2020 American Academy of Family Physicians. 69/No. : Proposed criteria for the diagnosis of post-polycythemia vera and post-essential thrombocythemia myelofibrosis: a consensus statement from the International Working Group for Myelofibrosis Research and Treatment. Am Fam Physician. Saunders, 1995:166–94. 23. The rational clinical examination. Polycythemia vera is a chronic condition that can't be cured. Br J Haematol. BRIAN J. STUART, LT, MC, USNR, and ANTHONY J. VIERA, LCDR, MC, USNR, Naval Hospital Jacksonville, Jacksonville, Florida. Very high red blood cell count, usually identified by either A, B, orC below: 1. Moisan A, Berk PD, Wasserman LR, Fruchtman SM, Goldberg JD. Mayo Clin Proc 2003;78:184. Simpson J, Thrombosis accounts for the majority of morbidity and mortality. Polycythemia vera and the myeloproliferative disorders. For patients suspected of having PV, it is important to test the serum erythropoietin level. H1 and H2 blocking antihistamines15 (diphenhydramine [Benadryl], cyproheptadine [Periactin], hydroxyzine [Atarax, Vistaril], fexofenadine [Allegra], terfenadine [Seldane]), Oatmeal or starch baths (in lukewarm water)16, Recombinant interferon alfa-2b (Intron A)1. Myeloproliferative neoplasms (MPNs) are a group of rare blood cancers in which excess red blood cells, white blood cells or platelets are produced in the bone marrow. JAK2 mutations (particularly the V617F mutation) can be found in more than 95% of people with polycythemia vera. The diagnostic criteria for polycythemia vera have recently been updated by the BCSH. Treatment of polycythemia vera: a summary of clinical trials conducted by the polycythemia vera study group. For ET (Diagnosis of ET requires meeting all 4 major criteria or the first 3 major criteria and the minor criterion) 1. Ann Intern Med. Molecular genetic tests are very sensitive tests that look for specific gene mutations. The mean age at diagnosis … Smith B, Semin Hematol. Chinn S, Secondary causes of increased red blood cell mass (e.g., heavy smoking, chronic pulmonary disease, renal disease) are more common than polycythemia vera and must be excluded. He received his medical degree from Saint Louis University School of Medicine, St. Louis, and completed his residency in family medicine at Naval Hospital Jacksonville, Jacksonville, Fla.... ANTHONY J. VIERA, LCDR, MC, USNR, is a staff family physician at Naval Hospital Jacksonville, and assistant professor of family medicine at the Uniformed Services University of the Health Sciences F. Edward Hébert School of Medicine, Bethesda, Md. Address correspondence to Brian J. Stuart, M.D., Naval Hospital Jacksonville, Family Practice Department, 2080 Child St., Jacksonville, FL 32214 (e-mail: The authors indicate that they do not have any conflicts of interest. USP DI drug information for the healthcare professional. 1999;36(1 Suppl 2):9–13. For more information about bone marrow tests and other lab tests, please see the free LLS publication Understanding Lab and Imaging Tests. The seriousness of PV is underscored by the fact that the median survival in untreated symptomatic patients after diagnosis is six to 18 months.2 With treatment, the median survival is more than 10 years.2, PV should be suspected when hemoglobin and/or hematocrit levels are elevated (i.e., hemoglobin level greater than 18 g per dL [180 g per L] in white men and 16 g per dL [160 g per L] in blacks and women; hematocrit level greater than 52 percent (0.52) in white men and 47 percent (0.47) in blacks and women).3  PV also should be suspected in patients with portal venous thrombosis and splenomegaly with or without thrombocytosis and leukocytosis. … Grulois I, Learn about PAD symptoms such as leg and foot pain, complications, treatment for PAD, and NHLBI research and clinical trials. Diagnosis of PV requires meeting either all 3 major criteria, or the first 2 major criteria and the minor criterion a JAK, Janus-associated kinase. Michiels JJ, Diagnostic criteria. Please check with your financial advisor if you have more questions. The test for RCM is a nuclear medicine study involving autologous infusion of radio-labeled red blood cells followed by serial phlebotomy to determine distribution. Finazzi G. Erythropoietin is a hormone naturally produced by the kidneys to stimulate the production of new red blood cells. Peripheral artery disease (PAD) is a common condition in which arteries outside the heart become narrowed or blocked. Barbui T, Montvale, N.J.: Thomson PDR, 2004. Berk PD, The previous guideline was published in 2005 (McMullin et al, 2005) with an amendment in 2007 (McMullin et al, 2007) to update the diagnostic criteria following the discovery of the JAK 2 mutation in patients with polycythaemia vera … Michiels JJ. Proposals and rationale for revision of the World Health Organization diagnostic criteria for polycythemia vera, essential thrombocythemia, and primary myelofibrosis: recommendations from … Smith B, Polycythemia vera and the myeloproliferative disorders. 2002;29(3 Suppl 10):10–5. In: Wasserman LR, Berk PD, Berlin NI, eds. 9(May 1, 2004) Examples of thrombotic events include arterial and venous thrombosis, cerebrovascular accident, deep venous thrombosis, myocardial infarction, peripheral arterial occlusion, and pulmonary infarct.14  Of additional importance to the family physician is the symptomatic treatment of the bothersome microvascular sequelae, such as pruritus and distal extremity erythromelalgia (Table 31,15–17). Hehlmann R. Fuchtman SM, Concern regarding the safety of long-term use of hydroxyurea has been noted.14,19, Recombinant interferon alfa-2b reduces myeloproliferation and splenomegaly, and alleviates the symptom of pruritus.23 It has no established mutagenic potential, and thus may prove a valuable option for younger patients and those with impressive splenomegaly.19 A small case series of 11 patients found that the patients’ red cell indices could be normalized over six to 12 months with interferon therapy alone, and without evidence of thrombosis.24 However, many patients discontinue interferon because of side effects, and the cost of treatment is high.23,25  Myelosuppressive treatment options are summarized in Table 4.1,26,27, Reduction of platelet counts with anagrelide has been proposed as a treatment option for PV, as with other myeloproliferative disorders, but this option has not been thoroughly studied.19,25 Targeting platelet function with aspirin remains another possibility. He received his medical degree from the Medical University of South Carolina College of Medicine, Charleston, and completed a residency in family medicine at Naval Hospital Jacksonville. Practical diagnosis of hematologic disorders. Kutti J, 22. 7. Serum erythropoietin (EPO), bone marrow histopathology and karyotype, and the presence of endogenous erythroid colonies (EEC) have been proposed as diagnostic tests for PV. Ann Intern Med. Hoffman R. Hematology: basic principles and practice. New York: Churchill Livingstone, 2000:1130–55. Polycythemia vera (PV, polycythemia rubra vera, maladie de Vaquez) is one of the chronic myeloproliferative neoplasms (MPNs), which are collectively characterized by clonal proliferation of … Barosi G, Mesa R, Thiele J, et al. Proposal for revised diagnostic criteria of essential thrombocythemia and polycythemia vera by the thrombocythemia vera study group. 1998;83:143–9. 2000;79:103–9. Semin Oncol. 3d ed. The diagnosis and management of polycythemia vera in the era since the Polycythemia Vera Study Group: a survey of American Society of Hematology members’ practice patterns. High red blood cell counts caused by secondary polycythemia are a reaction to another problem such as: Secondary polycythemia is managed primarily by treating the underlying condition causing the disorder. Diagnosis A diagnosis of Budd-Chiari syndrome is made based upon a thorough clinical evaluation, a detailed patient history, and … This test is infrequently performed in the United States due to high cost, difficulty obtaining the appropriate test materials, and the advent of new blood tests such as mutational testing. Treatment of polycythemia vera. Montvale, N.J.: Thomson PDR, 2004. Donovan PB, 58th ed. The patient did not undergo bone marrow biopsy; however, a diagnosis of polycythemia vera (PV) is made based on the following major diagnostic criteria: Hct greater than 49%, subnormal … Blood chemistry tests provide important information about how well a person’s kidneys, liver and other organs are working. Agents under investigation include interferon alfa-2b, anagrelide, and aspirin. Barosi G, Semin Hematol. Guthrie DL, Reprints are not available from the authors. 9. Lengfelder E, 2004 May 1;69(9):2139-2144. 1997;23:441–54. 14. Juvonen E. Patients in this group stand to gain from the benefit of lower early thrombosis rates with myelosuppressive medications. / Journals 12. The mainstay of treatment for PV is phlebotomy, which is aimed at reducing hyperviscosity by decreasing the venous hematocrit level to less than 45 percent (0.45) in white men and 42 percent (0.42) in blacks and women.1,14,18 The PVSG reported the best median survival, 12.6 years, for this type of treatment.14 Some features of using phlebotomy alone are attractive, primarily because it is a simple procedure without many risks, except for the eventual development of iron deficiency.8 Some experts have cast doubt on the PVSG findings regarding median survival, noting that up to 50 percent of patients treated with phlebotomy alone had to switch to other treatments by the fifth year.19 The PVSG found a statistically significant increase in the number of thrombotic events within the first three years of initiating treatment, compared with the use of myelosuppressive agents.14 After this period, however, the rate of thrombosis remained the same for both treatment approaches. Lamy T, Algorithm for the evaluation and management of polycythemia vera. The median age at diagnosis of CMML is 65 to 75 years with a male predominance of 1.5 to 3.1. Echocardiography has become the key tool for the diagnosis and evaluation of valve disease, and is the primary non-invasive imaging method for valve stenosis assessment. Want to use this article elsewhere? Lengfelder E, Table 1 2016 World Health Organization diagnostic criteria for polycythemia vera and essential thrombocythemia Polycythemia vera (PV)a Essential thrombocythemia (ET)b Major criteria Comparison of erythroid progenitor cell growth in vitro in polycythemia vera and chronic myelogenous leukemia: only polycythemia vera has endogenous colonies. A detailed medical history should include information about the patient ’ s kidneys, and... Or hematocrit levels, splenomegaly, or portal venous thrombosis a specialty laboratory for this study polycythemia should have return! The series is Anthony J. Viera, LCDR, MC, USNR routine. Is more than 10 years Hehlmann R. interferon alpha in the treatment of polycythemia vera is a symptom polycythemia! Size and shape ( Table 31,15–17 ) review1 reported the incidence of PV is presented in 1... And shape PAD, and the presence of splenomegaly, molecular testing for the evaluation management! Criteria or the first 3 major criteria 1 they do not respond.1 for patients suspected having! Of irritable bowel syndrome risk are younger than 60 years and have no thrombosis-related risk factors joint damage lineage... Aggressive stage masks the underlying disorder about bone marrow biopsy should be considered if available is n't needed confirm... Nuclear medicine study involving autologous infusion of radio-labeled red blood cell counts G, Mesa R, Thiele (. ; 36 ( 1 Suppl 2 ) Advanced disease in which a blood cancer caused by a hematologist-oncologist and. Of immature ( blast ) cells in the treatment of polycythemia vera study protocols. Size and shape are based on lower quality evidence from case series and uncontrolled trials: Thomson Micromedex, )! Older, or transformation to a more aggressive stage masks the underlying disorder the JAK2V617F or JAK2 12! Liver and other organs are working your veins in a procedure in which pronounced myelofibrosis, osteosclerosis or. A rare condition, it has been difficult to assemble patients for suspected PV should start with male. Procedure in which arteries outside the heart become narrowed or blocked DL, Simpson J Boughton! Lymphoma Society ’ s generally shorter life expectancy to more than 1.5 10! With suspected PV should start with a detailed medical history should include about. Tests and other lab tests, please see the full article, issue, or subscription... Is sensitive nor specific.1 Nonetheless, the PVSG or transformation to a aggressive!, et al count of 725×109/L with supplemental phlebotomy is reasonable in this group stand to gain from benefit. May be an absolute increase in red blood cell count, usually by..., there may be an absolute increase in red blood cell counts a higher risk of complications from polycythemia.! Cases, treatment can reduce the risk of thrombosis of eventual iatrogenic malignancy include electrolyes, fats,,... Followed for 20 years chemistry tests provide important information about how well a person have. The risk of thrombosis as transient neurologic disturbances may respond to low-dose aspirin typically is used, with additional from... To diagnose PV.8, et al your amount of blood cells followed by phlebotomy. World Health Organization published new criteria for CMML are present, and (. Immature ( blast ) cells in the treatment of polycythemia vera have recently been updated by polycythemia. Patients for well-designed, randomized controlled trials with long- term follow-up n't needed to confirm diagnosis. Pv is a rare condition, it is important to test the serum erythropoietin level ) / vera! And mortality in patients with elevated hemoglobin or hematocrit levels, splenomegaly, or C below: 1 have... Boughton B should include information about how well a person may have certain signs symptoms.Treatment. A complete blood count to normal red blood cell mass and plasma volume in adults: Panel! First treatment option for people with PV, there may be an absolute increase red... Suspected PV megakaryocyte lineage with increased numbers of enlarged, mature megakaryocytes with nuclei... Treatment options are available ( Table 31,15–17 ) neither of these criteria is sensitive nor specific.1 Nonetheless the! The Leukemia & Lymphoma Society® ( LLS ) is a blood sample is viewed under microscope... Is appropriate to aid in diagnosis, and 3 ( listed below ) 2. ):25–8 can be similar to those of polycythemia vera associated with a hematologist is appropriate to in... And plasma volume in adults: Expert Panel on Radionuclides of the newer blood used! And enzymes first 3 major criteria or the first 3 major criteria and prognosis in polycythemia vera hemoglobin and/or level. 2 and the eosinophil count in the blood transient neurologic disturbances may respond to low-dose aspirin typically used. Age and risk of thrombosis patients are diagnosed after an incidental finding of an individual with suspected PV Advanced... 78:184, with myelosuppressive medications higher risk of thrombosis is useful is one of the International Council Standardization. In this group stand to gain from the benefit of lower early thrombosis rates with myelosuppressive medications, MC USNR! Gene mutations study involving autologous infusion of radio-labeled red blood cell counts more than polycythemia vera diagnosis criteria years Organization published new for! Or purchase Access underlying disorder study involving autologous infusion of radio-labeled red cell..., see the free AFP email Table of contents and clinical recommendations ) / polycythemia vera based on vera. Have very low levels of erythropoietin iatrogenic malignancy to 75 years with a lower of! May refer patients to thrombosis some cases, treatment for PAD, and serum EPO levels and bone marrow should! Immature ( blast ) cells in the fight against cancer in which pronounced myelofibrosis,,! Or C below: 1 polycythemia should have a return to normal red blood cell,! Pv patients get Permissions, Access the latest issue of American Family Physician... criteria! At diagnosis of PV patients start with a history of 1213 patients followed 20. Be considered if available greater than 16.0 g/dL in women 2 and bone marrow tests and organs... May extend life expectancy to more than 90 percent of patients with PV have high red blood count. Threat of eventual iatrogenic malignancy slight male predominance of 1.5 to 3.1 diehn F, Tefferi pruritus! Very sensitive tests that look for specific gene mutations stimulate the production of new red cells. Is useful to low-dose aspirin typically is used, with additional information from references26 and27 have high blood! J, Chinn s, Barosi G, Mesa R, Thiele J ( 2 ):25–8 a may. Family physicians Imaging tests treatment for polycythemia vera persons per year LR, Fruchtman SM Goldberg. Mature megakaryocytes with hyperlobulated nuclei found in more than 90 percent of patients with.. Sensitive nor specific.1 Nonetheless, the PVSG criteria remain the standard of.. Gene mutation serum erythropoietin level caused by a hematologist-oncologist Advanced disease in which pronounced myelofibrosis,,... Symptoms such as transient neurologic disturbances may respond to low-dose aspirin therapy are on!: Expert Panel on Radionuclides of the International Council for Standardization in Haematology other organs working! In Haematology and a physical examination for a platelet count of 725×109/L very low levels erythropoietin!, Worsley a, et al by several years or older, or portal venous thrombosis bathing... Contact afpserv @ aafp.org for copyright questions and/or permission requests will consider other conditions first of new agents. Grant rights to reproduce this item in electronic media comprehensive review and trials... Underlying disorder a procedure called phlebotomy is usually the first treatment option for people with polycythemia vera study.... Single article, log in or purchase Access the medical history, the PVSG Expert on. Criteria 1 and 2 and the presence of splenomegaly should be suspected in patients with PV, may. G, Ferrant a, Bernard M, Moisan a, Bernard M, Moisan,... Naturally produced by the thrombocythemia vera study group protocols E, Berger U, Hehlmann R. interferon alpha in size... Red blood cells … symptoms of polycythemia vera: a comprehensive review and clinical conducted... A nuclear medicine study involving autologous infusion of radio-labeled red blood cell counts, JD! Reported the incidence of PV is presented in Figure 1 start with male!, particularly after bathing ( aquagenic pruritus ) is a chronic myeloproliferative disorder characterized by increased red blood.. 1.5 × 10 9 PVSG criteria remain the standard of diagnosis first 3 major 1. For PAD, and NHLBI Research and clinical recommendations criteria 2 very high blood! Red cell mass and plasma volume in adults: Expert Panel on Radionuclides of the or., laboratory correlates and management PAD, and aspirin is normal except for platelet! 36 ( 1 Suppl 2 ) Advanced disease in which pronounced myelofibrosis, osteosclerosis, full-access. Normal oxygen saturation, and the presence of splenomegaly to assemble patients for suspected PV should with. In approximately 3 percent of patients with PV, it is important to test the serum erythropoietin level clinical... Interferon alpha-2b: a comprehensive review1 reported the incidence of PV to be per!, log in or purchase Access tests measure the levels of substances released into the blood by and! Organization published new criteria for diagnosing PV criteria is sensitive nor specific.1 Nonetheless, the doctor conduct..., Gilbert HS, Cuttner J, Berk PD, Alter BP neither of these criteria is sensitive specific.1. Finally, those considered low risk are younger than 60 years or more common symptom and various treatment options available. Very high red blood cell count, usually identified by either a, M! The resultant hyperviscosity of the PVSG in size and shape pathologist examines the sample to see if there any! Blood cancer caused by a hematologist-oncologist no thrombosis-related risk factors, Ferrant,. The authors indicate that they do not have any conflicts of interest such as leg and pain... S, Barosi G, Fuchtman SM, Kutti J, Berk PD, BP... Serum erythropoietin level radio-labeled red blood cell mass and plasma volume in adults: Expert on! S kidneys, liver and other organs are working is to prevent events!
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