PRP injection for tennis elbow - successful or not?

Discussion in 'Health & Fitness' started by aussie, Jun 16, 2013.

  1. sovertennis

    sovertennis Semi-Pro

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    Aussie, good luck with your rehab. I, too, suffered with acute TE for several months (though not for nine months, as you did) and finally opted for surgery. After some diligent rehab, I was playing again, part time, in 6 weeks. Now, nearly two years later, I've not had a moment of pain. I hope your recovery goes just as well.
     
  2. Chas Tennis

    Chas Tennis Hall of Fame

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    Don't know much about this type of surgery and have not researched very well. Are there two main types of surgical treatment?

    1) Remove damaged part of tendon (s) and re-attach tendons to the bone.

    2) Make some cuts that do not involve re-attaching the tendon but free up the tendon somehow for some kind of remodeling.

    Do you know if your surgery could be characterized as one of the above procedures?
     
  3. aussie

    aussie Professional

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    Yes Chas my procedure was no. 1 above. The damaged portion is removed and the tendon (ECRB) is reattached to the lateral epicondyle. The lateral epicondyle is also roughed up to make a bleeding bed to accelerate the tendon healing process.

    When you read what the repair involves it's no wonder that there is a fair degree of pain and stiffness following the op. At 3.5 weeks after surgery I have full flexion with slight pain in the elbow and near full extension with a bit more pain. I have pain free suppination (turning palm up) with elbow flexed but substantial pain when suppinating with elbow in extension.

    I also have difficulty in making a fist because of pain and stiffness in mostly my middle finger. Not sure what has caused that but hopefully that will resolve over next few weeks. Next appointment with surgeon is in 2 weeks so my progress and way forward will be clearer after that.

    My understanding is that there are a number of procedures that surgeons employ to release/repair the ECRB. One is to cut the tendon to allow it to stretch thus releasing tension on the attachment to the epicondyle so that pain is resolved and healing can re-start. There are other techniques as well some using arthroscopies rather than the full incision method my surgeon employed. In the end you are in the hands of the surgeon and need to put your trust in him/her. Hopefully mine has done a great job!
     
  4. Chas Tennis

    Chas Tennis Hall of Fame

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    Why you might get pain with finger movements. The wrist extensors are probably most directly involved in Tennis Elbow. (?) As the video below shows, underneath the forearm wrist extensor muscles are the muscles that control the fingers. Several of these forearm tendons all attach together at the lateral epicondyle.

    This video describes the muscles of the forearm-
    http://www.youtube.com/watch?v=BjIab-huqgU&list=PLA42AC7FBC0B31765&index=18

    The subject of tendon attachment gets extremely complicated. As I understand it, the tendons may not each attach to the bone individually ("locally") but come together first in a structure some researchers call an "enthesis". I think that those researchers are viewing the enthesis as it's own structure with special pathology. Don't take my interpretation.

    Complex "Enthesis" description of tendons near the bone. Not easy reading....
    http://tt.tennis-warehouse.com/showpost.php?p=7779254&postcount=11

    Did they examine the removed tissue and provide any information to you on its condition, degree of tendinosis, etc. ?
     
    Last edited: Dec 3, 2013
  5. sovertennis

    sovertennis Semi-Pro

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    Chas--
    My surgery was also the first of the two options in your post (above).
     
  6. aussie

    aussie Professional

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    Thanks for posting the links Chas. very interesting viewing and reading and I'll need to replay and re-read to get my head around the information. First impressions leave you shaking your head at the complexity of the muscle and tendon anatomical construction just to be able to flex the fingers. Why we don't all suffer a myriad of finger, wrist, arm and elbow problems given the complexity is simply amazing. And this is just one relatively isolated part of our anatomy!

    Also I never thought to ask the surgeon regarding the condition of the tendonosis when I last saw him. If I remember when I see him in 2 weeks I'll ask but there is always so much info being absorbed during those appointments.
     
  7. ART ART

    ART ART Semi-Pro

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    @aussie: Hi, can you please update your status ?

    Hope you're doing fine!

    Cheers
     
  8. rufus_smith

    rufus_smith Professional

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  9. Junkie74

    Junkie74 New User

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    Hello!

    I did this procedure a couple of years ago, prior to that 10 years ago I had golfer's elbow surgery and the problems came back by over playing and a couple of stiff racquets along with some techniques flaws of course. To this day, i can't tell for sure if it helped me, It was painful I can tell you that and I had to rest for like 2 months along with physical therapy and maybe the rest time was all i needed to get cured and not the procedure ( I was desperate at the time ). bottom line for me, I don't think it worked like I had thought.

    Good luck!
     
  10. aussie

    aussie Professional

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    Guys I intend to give a complete update when I do get back to playing. In short, there have been complications following the surgery such as a minor frozen shoulder which I have 80% beaten which has impacted on my post TE surgery rehab. I still have more swelling in the lateral epicondyle region than the surgeon or I would like, so my recovery is taking more time than I would like. Hopefully though, still on track to play easy tennis by 6 months post surgery- around May/June. But, I will expand on this in the future once I am through all this and back on the court. Aussie
     
  11. ccmtennis

    ccmtennis Rookie

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    Things you wish your doctor told you

    I have just discovered this thread and read through it. First of I want to thank you for documenting your experience here for all to see and I hope this finds you well. I have been a TT member for a while but have not been very active due to work. I am moved by all that you went through and it reminds me of why we do what we do for patients.

    I wanted to share a few things with you as well as other TT members here who may read this. I am a physician scientist at a leading research university in the US, although not in sports medicine. More importantly my area of research is stem cells. This actually allows me to look at things critically and also as a tennis fanatic, a TE patient and most of all I do NOT have financial gain from any of this. I consider this an escape and love these boards. I am writing this in part because I am also upset on some amount of misinformation here provided by some physicians. Let's call this the "things that you wish your doctor told you" . I hope the mods don't delete this...

    First of PRP is not for everyone. It does clearly work for some including me, however it was very clear early in your description that it would not likely work for you. There is a lot of debate in the medical literature on this and for every study there is another to refute it. Most studies are flawed by lack of specifics in patient selection as well as a lack of a control i.e placebo (fake medication such as saline). A recent large study was finally attempted here
    http://www.ncbi.nlm.nih.gov/pubmed/23825183

    There were methological and statistical flaws but it appears that there may have been some benefit seen at a latter stage. For me, like most of you I experienced a lot more pain initially and had success 2-6 months later as seen in the literature. In addition to TE I had a sharp radiating pain with full extension and the MRI showed a partial tear along the common extensor tendon at the insertion. When I saw a colleague of mine well known in the field we had a long talk about it... details if you wish. I had 3 months rest followed by PRP twive at no charge at all so there is my disclaimer. 2 months later the pain is now an ache and it still allows me to play at a high level 2-3 times a week but likely not more. However I am no where at the severity of the OP.

    I wanted to clarify a few things if some of you are considering this. First of all there is still no conclusive evidence that PRP works for every case. It is an attempt to isolate healing cells (stem cells) which are scare in plasma but are still present. There was a poster here that mentions his doc gave him PRP as well as stem cells. I am sorry to say but this is no more than a placebo in science. We do NOT have the resources or technology to isolate stem cells that would work for your condition and I would not propose this to anyone except in the lab setting. Also there was a lot of mention about repeat ultrasounds and monitoring "neovascularization" i.e new vessel formation. I am sad to say that if your doctor promotes this, he is likely in private practice and gaining financially from you and I would consider looking elsewhere. Neovascilarization with a doppler ultrasound is highly controversial except with a tissue biopsy and lastly it has NO correlation with how patients heal and feel about their progress when blinded to it. Abundant data have shown this as well.

    Overall I hope that everyone who reads this understands that this is an evolving field even for those at the "cutting edge". There is very limited data but and anyone who claims to be an expert on this, you would need to look at what they have to back up their claims. What I am saying is that the best docs in this field always give options. There is no "one size fits all" unfortunately for us.
     
  12. aussie

    aussie Professional

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    Thanks ccmtennis for your well thought out post. I agree that PRP injections are not the "magic cure" for all tendonitis/tendonosis issues and certainly what works for one sufferer may not work for another.

    When I am asked by others whether having a PRP injection is a successful course of action to take for these types of issues my response is that it was not successful for me, but there have been too many sufferers of tennis elbow in particular who have experienced accelerated healing responses following the injection/s to discount it. For me, it was worth the time, discomfort and expense ($600 for the 2 injections) in a last ditch attempt to fix my TE before I went down the surgical repair path. I also believe that this is an evolving field of medical science that has a long way to go and there is much to learn.

    For me personally, my progress since surgery nearly 6 months ago has been much slower than I would like and was certainly hampered by a case of frozen shoulder I developed following the surgery. The frozen shoulder (adhesive capsulitis) is just about beaten and my elbow continues to improve. With my elbow flexed I can lift a lot of weight using my extensors (muscles on the back of my arm connecting to the lateral epicondyle - the site of the TE pain) without pain. I can grip with full strength anything with my elbow flexed without pain. For example, when I string racquets, I can squeeze the flying clamps without any pain - this was not possible before the surgery, I had to use my left hand or both to avoid pain. However, with my elbow in extension I still have some minor pain when lifting palm down or squeezing. Until I rid my elbow of this pain I do not consider myself ready for tennis.

    I perform strengthening exercises every day for the extensors and flexors using dumbells which I prefer over the Flexbar as I have more precise control over the amount of weight used. I incorporate a range of stretches as well as weights and though the improvement has been slow, there is still measurable improvement which is what keeps me positive.

    Finally, it so happens that I have an appointment with my upper limb surgeon this coming week so I may well have a clearer idea of what the future holds following that. Cheers for now, aussie.
     
  13. ccmtennis

    ccmtennis Rookie

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    Thanks for the update, it was good to hear certainly about your progress and please updates us on your progress. I'm sorry to hear about your shoulder but rest assured that I think the most important part of your healing is that your grip strength is great. That is one of the most critical part of the insertion tendon anatomy and I think the extensors will come along soon. All the best to you
     
  14. doctennis

    doctennis New User

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    Prp

    PRP can work for tennis elbow. Typically, it is used after stretching, strengthening, some rest and steroid shots have failed. Nothing is 100%, but PRP has been a nice addition to the treatment. Sometimes a second injection 6 weeks after the first can increase positive results. You need to shut down the tennis for 2-4 weeks following injection. We have obtained good results with PRP for tennis elbow but not all have succeeded. Did it to myself and received about 50% relief. Luckily not my racquet hand. PRP has no down sides based on current research so it is always worth a try. Surgery is a last resort option, but new techniques over the past 10 years do not require releasing or cutting any muscle or tendon. Return to play is quicker than in the past. Hope this helps, Aussie!
     
  15. aussie

    aussie Professional

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    A quick update. I am back to playing hard tennis one night a week even though my TE is not completely resolved. If I had to put a percentage on my elbow health, I would say it is about 80% right with 100% being absolutely no elbow pain.

    My accepting that my elbow may never be 100% and managing it with the right stretching regime, the right frame and string combo, some physical supports and some changes in how I play certain strokes have enabled me to get back on the court and play close to the competitive level I was playing 2 years ago.

    I will when I have a chance commence a new thread detailing how I have been able to manage the condition well enough to hit the court again.
     
  16. mikeler

    mikeler G.O.A.T.

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    Since you are using some already arm friendly Prince frames, let me suggest you buy the king of arm friendly Prince rackets. I can use full poly in this frame with no arm issues (coming from someone who struggled for years):

    http://www.tennis-warehouse.com/Prince_Tour_100T_ESP_Racquets/descpageRCPRINCE-PT100T.html
     
  17. aussie

    aussie Professional

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    Yes Mikeler I remember reading your many posts detailing your struggles against TE over the years and search for the most arm friendly frame possible. If I remember correctly you used the PK 7G for some time and felt it helped. I tried the 5G and while it was a great stick to play with I felt the kinetic bearings did little (at least for me) to soften shock and vibration to my elbow.

    Interesting you place the Tour 100T ESP above both the EXO3 Tour 100 models and Tour 100 models for arm friendliness as it ranks/rates below (worse in other words) those frames in vibration frequency, stiffness and weight which are 3 of the key indicators in determining arm comfort of a racquet.

    Just goes to show that our bodies are all unique as indeed our health issues can be and what works for one in terms of comfort, rehab etc may not be a perfect fit for another.
     
  18. sadowsk2

    sadowsk2 Rookie

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    Aussie- glad to hear you're back playing. From someone who is a little further along than you post-PRP, (I had mine done in Sept 2012 if memory serves), my elbow I would say is about 90%. It was 80% or so a year ago. I can now play all out 2-3 days a week... By all out I mean 2-2.5 hours a day, 3 sets of singles. It will generally be pretty sore for the following 24 hours and then go away. It is always there despite me doing 2 hours of physical therapy twice a week on it. I've become resigned that as long as I play tennis it will probably always be there... As long as I can maintain my current level of effort I'm more or less content.
     
  19. aussie

    aussie Professional

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    Thanks for the encouraging words. Yes I find that it is a matter of accepting that the elbow will never be 100% pain free and also that certain actions and positions will cause aggravation and pain. For example shaving and cleaning teeth still aggravates my elbow and causes some pain but with the appropriate massaging, stretching and bracing, tennis including one handed backhands causes less pain and is certainly within my acceptable pain tolerance level.

    I still feel that my elbow is improving, but the improvement is not in days or weeks but more in 3 monthly periods. And I do find that massaging the extensor muscles with a roller allied with stretching and range of movement exercises but NO STRENGTHENING EXERCISES is sufficient for my elbow to remain almost pain free. Flexbar and other eccentric exercises still irritate and cause some pain.

    As an aside, do you often wonder as I do, that we'd be in the same position with our elbows even if we had not undergone repair surgery? In other words, without surgical intervention, would rest and nature have healed our elbows to the same levels they are now?
     
  20. Mac33

    Mac33 Rookie

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    Around 10 years ago I developed tennis elbow playing squash.

    I turned up at the club one night and realised I had forgot my 180g Wilson Hamer frame.

    I borrowed another racquet,very light around 140g that had been strung much,much tighter.

    It wasn't till the next time on the court that I felt pain--- though the considerable impact of the super tight string and light frame was very noticeable at the time.

    Anyway,it took me 3 months to get rid of it. A few days off,then I would play.

    If I tried to play on consecutive days pain was too much.

    By accident I served a ball with more of a cutting technique one day and felt no pain. I continued using this technique on serve and pain went away!

    I understand your frustrations about not being able to pay the game you love so much---- but for me anyway,I would have waited quite a bit longer.

    Years ago,all this surgery was not so prevalent.

    Cutting into your body runs a considerable risk of damage.

    Directly injecting substances into the body,for one thing it's bypassing the body's own defence mechanism(of these substances).Just like with vaccinations,the side effects are considerable. Unfortunately many of these side effects are not seen till later in life. Auto-immune diseases are linked to direct injection.

    I'm a big believer the body can heal itself. With such a serious injury,more time is needed for the body to repair.

    Failing reasonable improvement from long term rest I would try using different techniques of hitting the ball. Perhaps flatter with a shorter swing etc.

    I would experiment with very loose string too,around 35 perhaps.

    TE---is an impact injury I believe. Loose string will put more energy back into the ball.

    A heavy frame,especially a head heavy frame should help too.

    A flexible frame seems to muffle the impact more.

    If little improvement resulted from long term rest----- I probably would give the game away.

    Understand for you that is not really a option.

    Best of luck healing.
     
  21. mikeler

    mikeler G.O.A.T.

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    The problem with all the measurements you mentioned is that it does not take into account the super open 16x16 pattern. I could not handle full poly in the 16x18 Exo3 Tour but I don't like anything but full poly in the Tour 100T ESP.
     
  22. the hack

    the hack New User

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    Got the torn epicondle from a stiff racket that hit so nice I didn't want to switch. Had the surgery, couldn't play for 6 months, came back using Kennex 5G. Have used several arm friendly rackets since, now use Kennex Blackace 98 with Babolat gut in mains and synthetic gut in crosses. I promise you that gut strings are easier on your arm then any synthetic. My elbow feels the shock immediately if I hit with all synthetic string at the 55# tension that I like. Thank goodness for gut strings. Still playing. Still hacking. Still working on my game.
     
  23. speedysteve

    speedysteve Professional

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    I have followed your tale of woe and am so glad to read your more recent update on improvement Aussie.
    Great that you are able to play again, even if at currently reduced capacity.
    I do hope you continue to recover and really beat it, and can play to your hearts content - every tennis players dream:)

    I have a minor (by comparison) battle with golfers elbow.
    Arm friendly racquets, nat gut and lower tensions are seeing me right tennis wise. Also changing my serve has been essential.

    I also use my arm for my other hobby - wood and metal turning and generally fabricating things, so I have had to re-learn doing some of those things and I recognise the clever left hand use when stringing racquets etc.

    Ice, rest and tens machine (electric shocks) are what helped me most in the beginning. I do like the Flexibar as it seems to get at the golfers elbow side of things more than wrist flexes with weights.

    Once again, great to hear of your progress and do let us know how you fair in the long run.
     
  24. JeffKang

    JeffKang New User

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    Err.. gonna repost my PRP comment here, instead of the “tennis elbow rehab article” thread.
    Didn’t know about this thread that specifically discusses PRP.

    **PRP evidence**

    > found a paucity of evidence from unbiased trials

    Comparative Effectiveness of Injection Therapies in Lateral Epicondylitis
    doi:10.1177/0363546512458237. PMID 22972856. Epub 2012 Sep 12.

    > but the apparent benefit of PRP dissipates over time

    Platelet-Rich Plasma as a Treatment for Patellar Tendinopathy
    A Double-Blind, Randomized Controlled Trial. January 30, 2014

    ajs.sagepub/com/content/early/2014/01/29/0363546513518416.abstract

    **Nonbulbar dermal sheath cells**

    Yahoo sports did an article a few months ago on the tendinosis (usually starts as tendinitis before becoming chronic) in soccer star Cristiano Ronaldo's patellar region/knees.

    The Yahoo journalist interviewed the CEO of a Vancouver company called RepliCel.

    They are working on a tendon treatment that will involve taking fibroblasts isolated from nonbulbar dermal sheath cells of a patient's own hair follicles, and injecting it into the damaged area.

    sports.yahoo/com/news/cristiano-ronaldo-s-obscure-injury-could-open-door-for-u-s-031401309-soccer.html

    > “Having spent much of his career researching treatments for tendinosis, Dr. Jack Taunton, professor at the University of British Columbia faculty of medicine’s CCV sports medicine division, says regenerative therapy holds great promise when dealing with chronic, long-term injuries.
    > “We’ve dealt with a number of these types of injuries caused by overuse or
    repetitive strain in thousands of patients.
    > Typically treatments have included physiotherapy, ice, anti-inflammatory’s, dextrose and **PRP [platelet-rich plasma]** injections.
    > Yet, we still have a significant population of patients that do not get better.”
    > He is hopeful that the upcoming RepliCel trials will improve those numbers given that hair follicle fibroblasts produce the amount of Type 1 collagen needed for fundamental repair of the tendon.

    business.financialpost/com/2014/09/09/new-technology-puts-your-own-cells-to-work-to-repair-and-rejuvenate-your-body/

    PRP might have a purpose, but once you have damaged tissue, or scar tissue, I don't think that supposed increased blood circulation is going to all of a sudden convert the scar tissue (e.g. for tendons, type 3 collagen) into healthy tissue (for tendons, type 1 collagen).

    >Replicel will initiate a Phase 1/2 clinical trial investigating the use of RCT-01 to treat patients suffering from chronic Achilles tendinosis.
    >NBDS cells are rich in of collagen-producing dermal fibroblasts necessary for tendon healing.
    >Chronic Achilles tendinosis is a degenerative disease of the tendon caused by a cycle of injury, improper healing and re-injury resulting in ongoing pain and loss of function.
    >Healthy functioning tendon is comprised largely of highly structured type 1 collagen wherein resident fibroblasts play a significant role in repair and maintenance.
    >In chronic tendinosis, it is believed that the resident fibroblast population is insufficient to complete the healing cycle.
    >These particular fibroblasts are easily isolated and expanded and are highly expressive of type 1 collagen and other extracellular proteins which are needed to reignite the healing process and support the regeneration of tendon for patients suffering from chronic tendinosis.

    Obaid, H.; Clarke, A.; Rosenfeld, P.; Leach, C.; Connell, D. (2012). "Skin-Derived Fibroblasts for the Treatment of Refractory Achilles Tendinosis: Preliminary Short-Term Results". The Journal of Bone & Joint Surgery 94 (3): 193–200. doi:10.2106/JBJS.J.00781. ISSN 0021-9355. Jbjs/org/content/94/3/193

    **EchoSoft ultrasound software, and reevaluating platelet-rich plasma**

    There's now a new ultrasound technology and software from the University of Wisconsin-Madison (Wisconsin Alumni Research Foundation), and Echometrix that not only uses waves for vision (conventional B-mode ultrasound), but the waves give quantitative data about functional characteristics, like stiffness (acoustoelasticity).

    echo-metrix/com/products.php

    It’s like looking at those heat maps on the Weather Channel.

    > Called EchoSoft, that technology analyzes previously unused information carried by ultrasound waves to **quantify** the extent of muscle and ligament injuries or a patient's progress in the healing process.
    > This technology applies the theory of acoustoelasticity to measure biological materials.
    > “EchoSoft is the first ultrasound-based product to provide a **quantitative analysis** of ligaments, tendons, and muscles as they naturally function,’” says Sam Adams, chief executive officer of Echometrix.
    > “The result is a clear, quantitative measurement that surpasses the diagnostic capabilities of a traditional ultrasound image.

    New Products". Journal of Orthopaedic & Sports Physical Therapy 40 (9): 598–601. 2010. doi:10.2519/jospt.2010.40.9.598. ISSN 0190-6011.

    While waiting for RepliCel, I might consider PRP for my tennis elbow (lateral epicondylitis) and wrist tendinosis if they do a proper trial with the Echosoft ultrasound software.
    No subjective reporting.
    I’d like to see data with numbers.
     
  25. aussie

    aussie Professional

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    Just to revert back to topic, I have a work college who is currently suffering TE bought on by a lot of motorcycle use. His wrist being constantly in an extended (bent backwards) position supporting his weight while undergoing the shock and vibration when riding has given him the dreaded TE. His girlfriends brother is an orthopedic surgeon here in Brisbane and says that there is just not enough evidence to recommend PRP injections. He is undergoing intensive physio and is now making progress after 6 months but once again shows that there is just no one definitive fix for this condition.
     

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