Cephalgia vs Proctalgia 

 Storm is coming... 

“You need to see a neurologist, specifically a headache specialist.”

“Fine, Doc, but I want to see someone around here. I don’t want to drive downtown.”

“I understand. I hate driving up there, too, so I would not push it if I did not feel strongly about it. There really isn’t anyone around here that I would recommend.”

“What about this guy?” He showed me the name of a neurologist from the nearby hospital that he had just pulled up on his smart phone.

“I would rather not send you there.”

“Why not?” He looked at me suspiciously.

“I really think you are going to get better care with this other physician.” What I wanted to say was that the one he had pulled up was bordering on quack, that he would order crazy amounts of completely unnecessary tests including a sleep study in the fellow’s sleep lab, multiple EEGs, a lumbar puncture, an MRI and an MRA, ungodly amounts of irrelevant lab tests and if the patient was lucky, would be told thousands of dollars later that there was nothing wrong except for migraines. If the patient was unlucky, he would be told that he had some rare, complicated disease and would need IVIG or some sort of other crazy, obscure treatment that would later be refuted by another neurologist. “You have migraines. I have tried everything I know to try. You need to move up to a specialist as maybe Botox or something else is in order.”

“I really want to see this guy.”

“He isn’t a headache specialist.”

“I still want to see him.” He narrowed his eyes.

“I can’t do that.” We had a stare down.

“I am not driving up there.”

“What about having a family member drive you? Taking a taxi?”

“No.”

“Please trust me.”

“Send me to this other guy.”

You know what? Screw it.

“Fine. I’ll send you.” I wrote the referral, feeling guilty. This is how patient satisfaction increases cost and morbidity/mortality….

I watched the consult notes coming back noting the negative EEG, the MRI, the MRA, the sleep study, the lumbar puncture, the ungodly amounts of irrelevant labs…

Final diagnosis? Migraines. 

A few months later the patient was back in my office.

“Say, Doc, thanks for sending me to that neurologist after all! He was so thorough.”

“Has he helped your migraines?”

“Well, no. Not yet…”

Here is a fascinating article from the New Yorker entitled Overkill. As physicians we like to point fingers at hospitals, drug companies, CEO salaries, equipment manufacturers and suppliers, etc. for the exploding costs of healthcare and while that is certainly true, there is a nice chunk of blame that should rest squarely on our own shoulders. This is the reason I have to battle the insurance companies like I did in my last post, Imaging. They know the secret we are not willing to admit to ourselves.

The reasons for over testing and over treating are numerous: patient pressure and expectation, protection from litigation, not being familiar with current guidelines, interest in personal financial gain, etc.

I would love to hear your thoughts! Do you think that your physician has ordered unnecessary tests? If so, why? What do you think their motivation was? Did you ask them of it was necessary? 

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122 thoughts on “Cephalgia vs Proctalgia 

  1. I don’t think we’ve ever had a physician that over medicated or suggested tests we didn’t think we’re necessary. I’m surprised this patient didn’t listen to you, especially after the many times you tried to lead him on another direction. I know some patients feel doctors recommend doctors to friends but if you trust your doctor and ask the right questions, that shouldn’t be an issue.

    Liked by 1 person

    • Some people have an intense fear of the downtown traffic. And for good reason. Plus there are parking fees and added facility fees tacked on to office visit charges often at these large centers. It is a tough thing riding the fence between professionalism and taking good care of patients. How much do you tell patients? How pushy do you get? And I would like to think that the vast majority of physicians are doing a great job not doing unnecessary things but it happens quite a lot, apparently, and patients have a hard time discerning since it is not their area of expertise. I love it when a patient asks me of something is really necessary. It shows they are an trying to be an educated consumer. Some patients just want me to decide and not bother them with the details. The article is a good read if you have the time. 🙂

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  2. Up until about 8 months ago I was with a surgery that did not care or seem to care snout patients at all. It was almost impossible to see a dr … Extra tests what tests you never got past a phone call ( amazing you are thing these drs diagnose over the phone they have xray eyes that work down the phone)
    So my new surgery seem amazing I can see a Dr anytime I need within reason. They do seem to do more tests but at last I feel someone cares, hell they know my name. Xxxxx

    Liked by 1 person

  3. “He was so thorough.”—Yep. Sadly, doing too much is often equated with being thorough. Clinical judgment has to way in, but often when doctors let it guide them, it doesn’t satisfy like ordering ‘every test under the sun’ does. Often not even for the doctor him or herself!

    Liked by 1 person

  4. To be honest, the only times where I think I have received unnecessary tests were when the doctor talked to me about them ahead of time and my understanding was that these tests were to make sure that I didn’t have to come back to see them. So I go through the tests and it turns out to be nothing or the most innocuous explanation. But now I know for sure what it is and I don’t have to come back!

    Also, my then-2-month-old son was given one of those “just in case” CAT scans which (surprise!) actually revealed a small skull fracture resulting in an overnight hospital stay. One night and $3500 out-of-pocket later he’s fine, but the not knowing would have driven me absolutely crazy.

    Peace of mind is very expensive but it is a trade-off I choose; I am fortunate to be at a point in my life where it is something I can choose without bankrupting my family.

    Liked by 1 person

  5. Holy cow, what a position to be in and with the ultimate inability to do anything short of coming out and calling another professional unethical and unqualified.
    Never had an issue with testing for a couple reasons: relatively healthy other than the arthritis and cervical cancer years ago, and I question everything plus discuss options. I am so adamant about pt responsibility and choice I can’t imagine simply agreeing to a test without researching and feeling confident that it was necessary.

    Liked by 2 people

  6. Hmmm, I see your point here but my experience has been of physicians missing something because they were unwilling to perform a test. As I’ve talked about here before my wifes breast cancer was diagnosed with a pat on the head and was told it was menopause. The doctor was wrong. So this makes me not trust what a doctor says. I want a test. The test found my wifes breast cancer; and just in the nick of time. We are also really lucky to have an oncologist in the family because we don’t have the luxury of seeing two or three family doctors to get a concencus. If our one and only family doctor says nothing is wrong and no tests are required then that’s it. If he’s wrong the consequence might be death. I do not advocate unnecessary tests but I am reluctant, now anyway, to take the word of just one doctor.

    Liked by 2 people

  7. The difference between fishing and thoroughness is a pretty fine line, isn’t it? In your patient’s case, a matter of perception. But, here, perception supported, or not, by background knowledge.

    I think how you react to this story depends on what you want your doctor to be (and, I admit, I haven’t got that completely figured out). I would like to think of my doctor as a member of the team (which also includes me) responsible for keeping my machinery healthy. The doctor is the one with the specialized knowledge about how the machinery works and how to repair or work around its brokenness. I’m the one with the specialized knowledge about what I want the machinery to do, and we have to work together to identify and achieve those objectives.

    The patient in the story seemed to be operating more from a service provider model such as you might apply to your house cleaners. That isn’t a collaborative effort. You simply tell them what you want done and provide the resources. If they don’t know how to get mold out of the shower, they may try lots of things before you call someone who does know.

    Liked by 1 person

    • I much prefer the collaborative model but it is interesting how few people really want that in reality. They *say* that is what they want but collaborative does mean what they think it means. They just want me to do what they want. Fine. I can work with that, too, generally. This individual I already knew from prior experiences. He was NOT going to give in. The real villain here isn’t the patient, though, it is the physician doing tests that are completely unnecessary.

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  8. My family doctor–no, although she is very thorough.

    My OB–yes. When I was pregnant, it seemed like all of the extra tests were unnecessary (constant ultrasounds, NSTs, blood tests, etc.), but it seemed like they were being extra cautious, not trying to bilk us. And even though the issues they were concerned about never came up, it turned out that it was all for the best in the end as being overly cautious likely saved the little one’s life.

    Liked by 1 person

    • The whole delivering kids, thing. It is hard. That is a field with high risk of litigation so presumably over treatment happens quite a bit. That being said, there are really great protocols and so depending on what was going on, even though it seemed like it was too much, it was also likely that it was just right…

      Liked by 1 person

  9. I think I’ve been very fortunate in that to my complete recollection, none of my physicians have gone overboard on tests. I did have one who ordered a colonoscopy for me at age 46 rather than 50, despite their not being a history of any colon or related cancer in my family. But that turned into more of a joke between us, as I held it over her head for a while on how she made me do something unpleasant six years earlier than I should have. Slightly off-point to your query, my only experience with overzealous doctors for tests have all been with dentists. I’ve paid more in fees than I care to think about for consults to oral surgeons and endodontists, only to be referred back to the original dentist with mundane recommendations such as that I use Sensodyne. Sometimes I do wonder if they’re washing each others hands a bit, financially speaking.

    Liked by 1 person

  10. This is wonderful insight for non-medical readers of your posts. I am lucky in this respect, being related to the medical community in this area. Since I taught medical students for many years, two of my three regular physicians (cardiologist, orthopod, internal med) are former students and I picked them because I knew they would make great doctors.

    Liked by 2 people

      • I too am fortunate when it comes to insider medical connections…baby sister is an RN who barters with me for apples when I ask basic medical stuff 😉 (really) it’s a win -win…brother in law is a psychiatrist, so he isn’t quite as helpful as sister,but on occasion. My father in law was a family Dr, who was old school/ you would have liked him) who died too young from Shy-Dragers. I know back when the kids were young, he too was a great sounding board for what was and was not necessary.

        Liked by 1 person

  11. There is this issue of CYA that a lot a physicians have to consider. I have declined having certain tests by my doctor. She made me sign a waver, which I happily did. I won’t go for a mammogram etc. This was all considered regular testing. You can take a stand if you feel strongly about things.
    I think I would have preferred the doctor you recommened because there are far to many doctors who do a lot of unneceassary testing.
    Leslie

    Liked by 2 people

  12. I haven’t had an experience with unnecessary tests. I did have an MRI last year on suspicion of something, and there wasn’t anything there. But there were reasonably sound reasons — family history and that it would be a major disaster if undetected — for suspecting.

    Liked by 1 person

  13. WRT your patient Victo – you tried to shepherd him in the right direction but he refused. On the upside – all the attention he is getting with testing is making him happy, so there is some psychological gain. Realistically though, i’m sure there are not a lot like him and most would respect your suggestions. The Bell curve reigns supreme – there will always be outliers, all you can do is suggest.

    My personal experience with testing is mixed. I’m a bit of an outlier myself because I have been so extensively involved with the medical community due to my medical needs. That being said, my personal take on testing is that the patient needs to understand their issues and be prepared to be involved in the decision making process that determines which tests and when. My default is if i can’t see why not, then I defer to the doctor’s recommendation. If I have an issue with a test, then i take my objections to the doctor and if i still feel strongly enough, cancel a test or demand a test be added.. Because i have spent so much time in and around hospitals I’ve seen both sides. I’ve had multiple doctors order the same test without realizing the other has already requested. When i get a notification of a test or a call, i always ask who requested the test and why. I carry this through until i am satisfied. Electronic records are a saving grace in this area – I just tell the doc to check my records and if he/she needs something that isn’t there, let me know and we can arrange it. Then there is common sense – some docs seem missing that component, preferring to follow recommended guidelines instead of thinking for themselves. i was having trouble with clotting in dialysis. They typically add a certain amount of heparin to avoid this and it wasn’t working. So the doc decides to do an ACT test to determine most effective heparin levels to avoid clotting. Made sense to me.The results however made little sense – the test findings recommended that they use 3,500 units of heparin during dialysis, which is very high – typically they use 500 -1500 units. I agreed to let them try this and during dialysis, I started throwing up blood. they hurriedly discontinued the heparin and found another, safer way to avoid the clotting. They then ordered an endoscopy to check because they said i had a stomach problem that caused the bleeding – I refused the test and told them the cause of the bleeding was obvious – way too much heparin. I agreed that if the problem returned that I would reconsider – but the problem never returned. To me that was common sense – to them I’m sure procedure says that any internal bleeding should be checked with an endoscopy.

    I am having issues with walking and feeling in my legs and feet. This is not uncommon with dialysis patients (and some other chronic care patients such as diabetics): peripheral neuropathy, a degradation of both sensory and motor nerve function in the legs (and some other peripherals). I recognized the symptoms and wanted a test to determine nerve activity. The docs did not want to order the testing – I assume because they knew what it was and knew there was no treatment or even understanding of what caused the condition..I insisted on the testing to confirm . for at least my peace of mind, and eventually they caved under my persistence and wrote the order. The test came back positive and confirmed nerve delay. In this case i had to pester to get a test. I’ve had other cases where I have noticed a change in my body that suggested a blood chemistry issue and have asked for blood tests without a doctor order. Some nurses check with a doc and some just do it – and i’ve caught some problems before anyone else noticed this way. Again, awareness and participation.

    Anyway Victo, I think patients should be more involved in decision making in their medical treatment – including testing. As I said, my case is somewhat unusual, so that may not be useful advice for others.

    Liked by 2 people

  14. Such an important and timely post, Victo. I’m going through this right now with my own mother – wading through continual tests. I can see both sides with respect to the doc and the patient, though. And the only answers I give her are communication and education. Seems like docs are so pressed for the first, and patients are often lacking in the latter. I just saw a comment you made about awareness and participation – I think we’re speaking the same language here! There’s no easy solution.

    Liked by 1 person

      • I’ve actually seem some amazing doctoring over the years – elegance in action. When they create a stoma for a colostomy, it has to be supported temporarily until it stabilizes in place. My surgeon (awesome guy)was quite chuffed that he found a sterile tubing in stock that had similar properties of strength and flexibility and diameter to the surgical product designed for the job. The official product was $26 for one unit – the tubing was 3 cents and it worked perfectly.. The stoma is still perfect after 11 years.

        Another time a young surgeon was setting a nephrostomy tube into my kidney -which was normally a painless procedure not requiring any sedative or even freezing,The kidney must have been inflamed and the pain was serious. They tried local anesthetic, freezing, everything they could and still the pain was unbearable . . they were pondering this when the surgeon’s eyes lit up and he asked if he could inject some freezing onto the neph tube that was still partially in place and couldn’t be touched without hurting me. I told him to try it and within a few seconds all the pain was gone and they finished the installation. Very brilliant and sensible.

        I could go on Victo, but I’ve seen some amazing doctoring.

        Liked by 1 person

  15. Here in the UK the situation goes as far the other way. The National Health Service relies too much on “watchful waiting”, which tends to supplant diagnostic thoroughness IMHO. And of course “watchful waiting” is often merely a euphemism for managing costs on big ticket diagnostic testing. Comparing outcomes with other social health systems in Europe shows the results of under-diagnosis.

    Liked by 1 person

  16. I’ve had the opposite experience. When I started experiencing excruciating pain in my hip, my doctor did not order hip X-rays because I was “too young for osteoarthritis” even though I had classical symptoms. I was 52 but I was — and had been for many years — a trail runner and I’d sustained numerous injuries over the years. It took him TWO YEARS to order hip X-rays which revealed bone-on-bone osteoarthritis. By then, I could not walk without a cane and with a cane I could not walk very far. I hate him to this day.

    He was not the only one. Several years later, I had very sudden onset asthma and intense nasal congestion. My doc gave me everything she thought of then she complained to me, “Why aren’t you well?” Two YEARS later (unable to taste or smell, sometimes so short of oxygen I felt woozy and sure I was not going to be helped by my doctor) I sent myself to an ENT. He found nasal polyps and an acute sinus infection. He gave me meds and sent me to an allergist. Within a day I was breathing again. The diagnosis turned out to be a relatively rare condition known as Samter’s Triad.

    I believe in treating symptoms but I think it’s also important to look for an underlying cause. If I’d been these two “doctors” I’d have x-rayed my hips and sent me to a specialist when the first and most common remedy for asthma had no effect.

    Liked by 1 person

      • It’s OK — but it’s why I’m now very direct when I interact with my doctor — a woman I think is not just competent but “gets” me. She’s wonderful. I might do just what your patient did but not for the reason that I didn’t want to drive. That’s just silly.

        Liked by 1 person

  17. Question, Doc. Is it just a matter of professional courtesy, or is there liability when you say something to discourage a patient from a questionable specialist ? Could you have warned that patient about the concerns you listed here ? Just curious. ☺ Van

    Liked by 1 person

  18. I’ve never locked horns with my doctor. Anyway, the less poking and prodding, the happier I am. Parking costs are atrocious and I’m happy at home doing what I enjoy rather than sitting in waiting rooms because I may live a boring life. 🙂

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  19. I wish we could go back to the good old days when excessive ordering didn’t equate to patient satisfaction.What ever happened to the good ‘ol trustworthy doctor-patient relationship?..but then again, appointments were probably longer back then. Sometimes it’s easier to just order a test or prescribe the latest brand drug these days. I fight those pressures in my practice every day.

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  20. Here in the UK, as stated previously, the docs tend to under diagnose on account of cost. My first GP treated me for 10 years with menometrorrhagia and never bothered to do a single blood test. As a patient here, we don’t tend to make such requests. By chance, after a particularly bad weekend, I saw a different doctor in the same practice. On hearing I was shivering with cold and dropping off to sleep in the middle of ordinary conversation, she ordered a blood test at long last. I had lost about half my blood volume in a night, and had a decade of gross anemia undiagnosed, thanks to a lack of “unnecessary” testing. The pendulum swings both ways, I guess. Having said that, I have otherwise received excellent care over here overall. My current GP, who is actually German, is fantastic. No complaints! 🙂

    Liked by 1 person

  21. My doctor plays it safe and that anything beyond plain vanilla doctoring is referred to a specialist. That’s a bit of an exaggeration but I get the feeling that she’s looking for second opinions and it’s a change from the more self-confident doctors I’ve had in past. Having celebrated my half century a couple years back, I comfortable with this playing-it-safe especially as I don’t have the feeling I’m getting needless or excessive treatments e.g. I’m not getting long lists of medications to take when I have a simple cold,

    BTW: LOL at the post title. 🙂

    Liked by 2 people

  22. I’m fortunate to have very good health care. I don’t get a lot of tests, unless I genuinely need them. I’ve recently had an experience of their triage system when I became the unexpected emergency. First rate. Lots of tests, but I don’t begrudge them. My final diagnosis was migraine, although my presenting symptoms were visual hallucinations. Lots of tests and specialists, but necessary, since these were the auras from hell. I’ve had migraines with auras for years, but this one was a doozy!

    Liked by 1 person

  23. Even with all of my medical issues, I don’t feel my doctors prescribe too many tests. They do recommend too many different specialists, though. Whenever I have a minor/medium issue, my GI pulls out her rolodex and suggests I see a specialist. Sometimes I agree and do it. But being stiff in the morning isn’t really reason to see an orthopedist!

    I do have an issue with doctors never wanting to say bad things about another doctor. How do we know which is which? (That being said, you did give enough clues to this patient. They just didn’t want to hear them.) There are good and bad doctors, just like any other profession. I prefer to go to the good ones, thank you very much.

    Liked by 1 person

  24. I can tell you that (here in northern Virginia (DC area, USA) veterinarians are also engaging in “overkill.” The cat i lost recently (a core part of my life for 13 years)… the vet did a huge battery of tests after which my cat was so traumatized that he was paralyzed for at least 5 minutes. The results came back, “He is perfectly healthy for his age.” > I asked why he still vomited. “In that case there are still a lot more tests we need to do.” I demanded a medicine to make him more comfortable while he developed a diagnosis. The vet refused to give so much as pepcid before he had done every test he knew. When i refused to torture my pet, he also refused to refill the prescription for my other cat.
    I will curse that quack with my dying breath.

    Liked by 1 person

  25. I once had to go through three CAT scans of my sinuses to get a diagnosis of a deviated septum. The ENT wanted to do surgery for a chronic sinus infection. I pointed out that the three radiology reports indicated I had a deviated septum. So then he decided to do surgery for a deviated septum. The surgery went okay, and I stopped getting all those severe headaches, but I still wonder if there’s any lasting damage from three CAT scans over a 7-month period.

    Liked by 1 person

  26. I have been on both sides. Doctors who wanted to test everything they could but never find anything conclusive. I also have had the reverse where I have begged to be tested for something and been told it was …not playing victim here but this is the truth…that what ever the issue it was because I was fat. It took my hands to curl like claws before the finally tested for RA and guess what they found….. idiots. I have different doctors now.
    My PCP and rheumatologist are the best. They let me hammer things out and not over medicate or over test until we are sure. I am a real pain in the ass patient because I research everything. But I am informed. My PCP was laughing with me last week when my labs all came back in great shape. I told him to let me work on things and dropped all my number significantly without medication. I love being right! 🙂

    Liked by 1 person

    • I hear similar stories from patients about doctors blaming things on fat that turn out to be real. Can it be possible that is so prevalent? Or is it sometimes misinterpreted? Not having been there, I do not know. That being said, it is interesting the studies on weight and longevity. Makes one wonder if we are blaming too much on weight….

      Liked by 1 person

      • Oh it is real believe me. It is a tricky line because there are many things that are caused by being fat. I get that and I don’t deny there is correlation. However, for me for example, I went from playing competitive tennis 3 x per week for many years to being unable to walk or write in about a matter of four months. My weight did not change….. Believe me, this is one small example but cost me dearly. The damage done while they dicked around is irreversible.

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  27. It’s something I’ve battled with a lot during practice. Overkill, both in investigations and treatment. We like to help our patients, how we can do that becomes tricky at times. I’ve also had to do what I didn’t think was the right thing to do in the longer term interest of the patient. I thought it better that he/she got a little overtreatment from me where I could look out for any potential complications than that he/she go to a quack and get way overtreated and get worse. A case in point, I saw a patient yesterday with a long standing cough and headache who had been treated with five different antibiotics simultaneously (from Sulbactam to Moxifloxacin), two analgesics and three injectible medications. He’d paid a bundle for investigations ranging from blood studies to an MRI, with no diagnosis but a bouquet of medicines. The guy had lost 8 kg in the last month. I advised him to stop all medications and just rest, eat properly and come back in a fortnight.

    Liked by 1 person

  28. Well being in Canada I’m guessing things are different but I can’t seem to get my doc to do the tests he and I both know I need. He mumbles something under his breath about it being too costly.

    Liked by 1 person

  29. My physician sent me to a cardiologist for a stress test because he was a bit concerned. I have no argument there.
    The cardiologist sent me for massive tests in his private hospital and there was nothing conclusive so my physician sent me for a gastroscopy and found I had a hiatus hernia. The physician and the gastroscopy fellow were doing the best they could.
    The cardiologist had set himself up to make as much out of things as he could. There is good guys and there is bad guys. It’s the real world. Money money money and some good guys.

    Liked by 1 person

  30. I think patient expectations have a lot to do with it. I’ve learned that often (unfortunately far too often for the filled-with-facts world we live in) the doctor just doesn’t know what’s wrong, is not going to find out no matter what test is done, and won’t really be able to solve the problem. Our bodies don’t function perfectly and there’s much that doctors just don’t know and can’t do. But no one wants to hear that.

    Liked by 1 person

  31. This is where the British way of only doing the really essential tests works well. But that is not 100 %, of course. But I still believe that the most important medical tool is an analytical brain combined with common sense.

    Liked by 1 person

    • That is the thing. Too many physicians have stopped thinking and do not know how to perform a proper history and physical. At least the new docs I am coming in contact with in my area.

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  32. And that in a nutshell is my great fear of doctors, that medical conveyor belt of tests, procedures and visits. I guess we’re all different. I like a calm, easy-going doctor. Some people like “thorough” doctors who make them go through the gauntlet of medical exams. That’s why it pays to take care of yourself, to avoid all this to begin with.

    Liked by 1 person

  33. I’m in the military Tricare network. There are never extra tests, it’s nice because I hate unnecessary testing. It’s not thorough, it can be painful, expensive, AND it makes me think you don’t know what you’re doing.

    Liked by 1 person

  34. Pingback: My Article Read (5-11-2015) (5-12-2015) | My Daily Musing

  35. Wow. I sure wish you were my doctor! When I have a doctor that listens, I usually listen to their advice and trust them completely. When I have the occasion to have a doctor who doesn’t seem to hear me, I usually do my own research first then tell him/her what I want tested and argue until I get it. In those occasions, I’ve actually always been spot-on, too, though years of medical research for attorneys have aided in my finding a solution. I’d never recommend that for just anyone.

    Liked by 1 person

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