Presidential address: Society and vascular surgery—The need for humanism and research
1992; Elsevier BV; Volume: 15; Issue: 2 Linguagem: Inglês
10.1016/0741-5214(92)90248-7
ISSN1097-6809
Autores Tópico(s)Aortic aneurysm repair treatments
ResumoIt is with profound gratitude and humility that I address you today. I am thankful for the privilege of being president of the oldest society in North America dedicated to vascular surgery. I am also humbled by the knowledge that many of you are far more deserving of this honor than I, and I am further humbled after reviewing the distinguished list of past presidents, the giants of vascular surgery. Society has provided me the privilege of being a surgeon. What other profession affords the satisfaction of helping your fellow human, having fun doing it, and also being paid for it? None that I know of. Therefore I am not only indebted to you my family, friends, residents, students, and colleagues but to society as well. When I was reflecting on and considering various topics for this presentation, the responsibility became all the more formidable after reading the 41 previous presidential addresses. Three, for various reasons, were not given or published, but the other 41 covered wide-ranging topics. Twenty-one were mainly scientific. Those of the earliest years, not surprisingly, dealt with venous diseases, since arterial reconstruction and cardiac surgical procedures had not yet been performed or perfected. Then came the cardiac surgery explosion of the 1950s and 1960s, which compelled 11 presidents to present cardiac surgical papers, beginning with Blalock in his 1952 address.1Johns TNP Williams GR Blalock A. The anatomy of pulmonary stenosis and atresia with comments on surgical therapy.Surgery. 1953; 33: 161-172PubMed Google Scholar It is curious that although the early 1950s heralded the dawn of vascular surgery, and seminal discoveries and innovative procedures were being pioneered by our presidents, over the past 44 years only three presidents discussed arterial disease, the first being Linton in 1955.2Linton RR. Some practical considerations in the surgery of blood vessel grafts.Surgery. 1955; 38: 817-834PubMed Google Scholar Four presidents presented historical perspectives of the Society for Vascular Surgery, and seven addresses were philosophic. Although biomedical science comprised 17 of the first 20 published presidential addresses, only 3 of the last 21 were scientific reports. This may reflect the maturing of the Society for Vascular Surgery and our becoming involved in societal issues as a result of and in response to contemporary pressures, since eight presidents addressed the issues of training and certification, all within the past 20 years. These presidents including Drs. Wiley F. Barker, James A. DeWeese, F. William Blaisdell, John A. Mannick, H. Edward Garrett, Anthony M. Imparato, Wesley S. Moore, and William J. Fry provided much of the leadership during the intermittently tumultuous times of acquiring specialty status and certification by the American Board of Surgery for General Vascular Surgery. 3Barker WF. What the Society for Vascular Surgery ought to be.Surgery. 1973; 74: 797-802PubMed Google Scholar, 4DeWeese JA. Vascular surgery—is it different?.Surgery. 1978; 84: 733-738PubMed Google Scholar, 5Blaisdell EW. Vascular surgery training: quo vadis.Surgery. 1979; 86: 783-790PubMed Google Scholar, 6Mannick JA. Presidential address: Vascular surgery—“a part of the main.”.Surgery. 1981; 90: 927-931PubMed Google Scholar, 7Garrett HE. Presidential address: evaluation and endorsement of vascular training programs and certificate of qualification in general vascular surgery.Surgery. 1982; 92: 915-920PubMed Google Scholar, 8Imparato AM. Presidential address: the carotid bifurcation plaque—a model for the study of atherosclerosis.J Vasc Surg. 1986; 3: 249-255PubMed Scopus (13) Google Scholar, 9Moore WS. Presidential address: vascular surgery—a continuing quest for excellence.J Vasc Surg. 1988; 7: 185-189PubMed Scopus (5) Google Scholar, 10Fry WJ. Presidential address: who sets the standards?.J Vasc Surg. 1991; 13: 6-8Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Parenthetically, the Society for Vascular Surgery along with the North American Chapter of the International Society for Cardiovascular Surgery should take great pride in the realization that since 1984 the addresses have been published in the Journal of Vascular Surgery an SVS/ISCVS-Mosby-Year Book, Inc. jointly owned and highly successful periodical. Although the bylaws of the Society emphasize the need “To promote the study and research in vascular diseases,” it is both curious and disappointing that only four presidents emphasized need for supporting research, beginning with the 1968 address by Dr. Wilfred G. Bigelow, the only Canadian to hold the office of president.11Bigelow WG. Intellectual humility in medical practice and research.Surgery. 1969; 65: 1-9PubMed Google Scholar Since then Drs. Andrew Glenn Morrow, Allan D. Callow, and most recently D. Eugene Strandness, Jr. have stressed the need to promote research. 12Morrow AG. What the cardiac surgeon ought to be.Surgery. 1972; 72: 819-826PubMed Google Scholar, 13Callow AD. Presidential address: the microcosm of the arterial wall—a plea for research.J Vasc Surg. 1987; 5: 1-18PubMed Scopus (22) Google Scholar, 14Strandness Jr., DE Presidential address: one man's odyssey.J Vasc Surg. 1990; 11: 187-192Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Strandness noted, “Research in vascular disease must remain a primary focus for the academic surgeon; without it we will die as a vibrant specialty.”14Strandness Jr., DE Presidential address: one man's odyssey.J Vasc Surg. 1990; 11: 187-192Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Callow wrote, “What is needed is knowledge and such knowledge will be provided by the young among us and those yet to come.”13Callow AD. Presidential address: the microcosm of the arterial wall—a plea for research.J Vasc Surg. 1987; 5: 1-18PubMed Scopus (22) Google Scholar Addressing funding for research Callow suggested, “…we must not depend exclusively on the NIH to provide us with our funds. We must seek other sources.”13Callow AD. Presidential address: the microcosm of the arterial wall—a plea for research.J Vasc Surg. 1987; 5: 1-18PubMed Scopus (22) Google Scholar I will expand on this theme because I firmly believe that we must be producers of surgical knowledge not simply consumers of it. Production of surgical knowledge by supporting and nurturing surgeon-scientists and then applying that knowledge with humanism is, in my view, our obligation to society for the privilege of being surgeons. Humanistic application of knowledge acquired through research is how the Society for Vascular Surgery can best perpetually serve society. Although I have chosen humanism and the nurturing of surgeon-scientists for this essay as the two pivotal issues on which we should collectively focus and expend most of our energies and resources, because only they assure the most lasting and long-term benefits, many other pressing societal issues merit our individual consideration. Dr. C. Everett Koop, the former Surgeon General of the United States, in his lecture to the 1990 Clinical Congress of the American College of Surgeons cited several such issues.15Koop CE. Exasperation on both sides of the stethoscope.Bull Am Coll Surg. 1991; 76: 8-17PubMed Google Scholar Some concerns are “cheap shots” by the misinformed, misguided, and arrogant media.16Jaffe BM. Cheap shots.Surg Rounds. 1990; : 11-15Google Scholar Some of the media “doctor bashing,” however, may be justified, particularly that relating to Peer Influenced Group Seminars (PIGS), which are nothing more than minivacations disguised as continuing medical education courses sponsored by industry. Equally concerning are conflicts of interest and industrial marketing techniques, preoccupation with fees and unbundled billing practices, abuses of noninvasive vascular laboratory testing such as performing and billing for three tests when only one can be justified, entrepreneurial surgeons who self-servingly tout unproven treatments, and advertising. Concern for physician reimbursement reforms probably consumes more of our Society's energies than is warranted, considering that vascular surgical costs are such a minuscule element in the $650 billion health care expenditure equation and also considering that we are well represented in Washington D.C. by the American College of Surgeons. Society is furious over the estimated 22% administrative costs of health care spending, and associated mismanagement, waste, and fraud. Further agitating society is the lack of affordable quality health coverage for an estimated 33 to 37 million Americans who are virtually uninsured. Added to the ineffectiveness of Medicare and Medicaid programs are fraudulent health insurance practices where patients' premiums are collected but hospital and doctor bills are never paid. Research and publication fraud are also attracting societal concerns, exemplified by the extraordinary cases of the prestidigations and fabrications of Drs. Darsee and Slutsky. 17Relman AS. Lessons from the Darsee affair.N Engl J Med. 1983; 308: 1415-1417Crossref PubMed Scopus (104) Google Scholar, 18Engler RL Covell JW Friedman PJ Kitcher PS Peters RM. Misrepresentation and responsibility in medical research.N Engl J Med. 1987; 317: 1383-1389Crossref PubMed Scopus (109) Google Scholar In addition, excessive and frivolous disbursement of indirect monies intended to support research are equally troubling. Another issue gaining public attention that requires thoughtful resolution is that of the surgeon impaired by health defects, drugs, or alcohol. Society has been led to believe that significant surgeon impairment results from working too many hours a day. What has not been adequately emphasized is that restrictive work practices preclude continuity of care. Lack of continuity of care, I suggest, will lead to many more mistakes and adverse outcomes than overwork. Harassment by managed care administrators and “peer” review organizations detracts from our patient care efforts by consuming valuable time with paperwork and nonproductive committee meetings. Health outcomes analyses without risk stratification also impair optimal patient care. Medical liability issues and the practice of defensive medicine clearly increase health care costs and are receiving needed but limited attention through tort reform legislation. Such added costs are receiving societal scrutiny with the looming specter of rationing of medical care. But will rationing be by age, disease, severity of disease, or ability to pay? Will euthanasia be an alternative? Easy answers are not forthcoming. These are the many but by no means all of the societal issues challenging medicine for solutions. What should be the response of the Society for Vascular Surgery to this litany of concerns? I suggest that the answer may be found in “The Boundaries of Medicine,” Dr. Donald Seldon's 1980 presidential address to the Association of American Physicians when he cautioned physicians and surgeons not to venture outside the boundaries of our competence.19Seldin DW. The boundaries of medicine.Trans Assn Am Phys. 1981; 94: 75-86Google Scholar That is not to say that we should not be concerned and involved, but just because surgery and medicine have made dramatic and major technological advances, such advances do not confer infallibility on us. We must guard against the medicalization of society as the solution to all human problems. We must leave solutions to the problems of poverty, drug abuse, starvation, and murder to others in our society such as economists, anthropologists, sociologists, political scientists, and even politicians. As vascular surgeons we must resist the temptation to medicalize society, because such medicalization requires resources beyond our capacities. As Seldon noted, “The economic, social, and cultural structure of society influences health profoundly. However, this influence is exerted through forces over which medicine has little control and cannot alter. Admittedly, disturbances in political, economic, and social organization may express themselves in serious medical disability, yet the causes generating these illness lie outside the arena of medicine.”19Seldin DW. The boundaries of medicine.Trans Assn Am Phys. 1981; 94: 75-86Google Scholar I suspect that most, if not all, of the socioeconomic issues cited will ultimately be solved with or without vascular surgery's input, and will be replaced with a new list of issues. But nonetheless, 10 years hence today's concerns will be of historical interest only. Such transient but important issues, in which we should be individually involved to some degree, are largely political whims motivated by economic expediency, and they change from year to year. Collectively we must be careful not to dilute our efforts by addressing tasks we are not prepared for either by experience and knowledge or resources. Our focus should be not on how these problems affect us, but how they affect our patients. Attacking such issues without enlisting patient (society's) support is self serving, and all such efforts are doomed to fail. We should focus on what we know and do best, which is to care for the patient with diligence and humanism and advance the science and perpetuation of vascular surgery through research. It is both ironic and disturbing that in the country with the best medical care in the world, medicine and physicians in particular are losing the respect of society. In a recent AMA public opinion poll, almost 60% of Americans responded, “doctors don't care about people as much as they used to,” and almost two thirds responded, “doctors are too interested in making money.”20Harvey LK Shubart SC Public opinion on health care issues in 1989.Am Med Assn. April, 1989; (Chicago, Ill)Google Scholar Such societal dismay is embodied in the opening sentence of Charles Dickens'21Dickens C A tale of two cities.in: TB Peterson and Brothers, Philadelphia1859: 1Google Scholar 1859 book, A Tale of Two Cities where he wrote,“It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going direct to heaven, we were all going direct the other way-…” This nineteenth century quotation has become a twentieth century reality, and we are victims of our own successes. Late twentieth century technology has separated the surgeon from the patient and has in effect dehumanized care. Society, although impressed by our technological accomplishments and grateful for the results provided by such advances, is increasingly disenchanted by our lack of humanism. Dr. Frederick A. Coller, who had great influence on me during medical school at the University of Michigan, in his 1950 American College of Surgeons presidential address emphasized humanism as central to exemplary and optimal patient care.22Collet FA. For the benefit of the patient.Bull Am Coll Surg. 1951; 35: 29-34Google Scholar Lack of humanism in 1991 may be the main reason why society views physicians with cynicism and suspicion. Humanism means different things to different people. Random House dictionary defines it as, “A mode of thought or action in which human interests, values, and dignity are taken to be of primary importance.”23Random House College Dictionary. Random House, Inc, New York, NY1975Google Scholar Webster's Third New International dictionary defines it as, “Devotion to human welfare, interest in or concern for man.”24Webster's Third New International Dictionary. Merriam-Webster Inc, Springfield, Mass1981Google Scholar Humanism is not the wringing of hands, raising false hopes, and providing reassurance when none is warranted. Humanism does, however, embrace mutual trust, honesty, altruism, compassion, and knowledge of the patient, his disease, and his family. Sensitivity to our patients' needs, minimizing waiting, respect for their dignity and privacy, respect for their right of choice, and meeting patients' and their families' desires for information embodies the humanistic approach to vascular surgery. Many would attempt to dehumanize vascular surgical care, some unintentionally because they are poorly informed and others because of entrepreneurial commercially driven incentives. Dehumanization is exacerbated by the media advertising things that we surgeons cannot deliver. It is not uncommon that the media, in their zeal to report results from the New England Journal of Medicine on the evening news, misrepresent or perhaps unwittingly provide half-truths that sound like spectacular breakthroughs, which only later prove to be unsubstantiated or disproved as new data come to light. Misleading information is epitomized by marketers employed by hospitals or physician groups to extol the virtues of a treatment or professional capability simply to gain a “business” edge over competitors. It is clear that marketers market marketing, that is their job. But inevitably, society becomes disappointed, and physicians and surgeons, not the media or marketers, are held responsible and accountable for failures of treatment. We must not allow our patients to be misled by unrealistic media hype and marketing that imply infallibility. Unrealistic expectations promulgated by aggressive or misinformed media must be reviewed by surgeons and vigorously refuted when necessary. However, only through communication, education, and cooperation and not confrontation can this be accomplished. Unless we effectively address this issue, all will lose, patients will be disappointed, and skeptical and surgeons will lose the respect and confidence of society. Humanism does not include entrepreneurism. Dr. Frank Spencer's admonition, that the physician cannot be a double agent serving both the patient and the marketplace, must be heeded.25Spencer FC. The vital role in medicine of commitment to the patient.Bull Am Coll Surg. 1990; 75: 8-19PubMed Google Scholar Dehumanization is further exacerbated by managed care administrators and entrepreneurs when they refer to patients as “clients,” “consumers,” or “customers” and physicians as “providers,” “health care workers,” or “care givers.” Surgeons, in particular, are demeaned and should take great exception to being referred to as “proceduralists” or “technicians,” connotations that have been perceived to separate us from our patients. Parenthetically, we are as much to blame as anyone for the perception that we are nonthinking technicians and nonhumanists when we demean our specialty by equating “operation” with “surgery.” To me it is heretical to “take a patient to surgery” and to do “surgery” or “surgerize” the patient or perform “surgeries.”26Ernst CB Surgery, the abused word.Surg Gynecol Obstet. 1975; 240: 608Google Scholar Such misuse of the word “surgery” relegates us to the status of a technician and moves us from a profession to a trade with corresponding lack of humanism and ethics. It is clear that vascular surgeons are much more than tradesmen who by definition have little opportunity to display humanism. Few, if any other specialties, have the breadth and scope of vascular surgery that encompasses preoperative, operative, and postoperative care and long-term follow-up. With rare exceptions, vascular surgeons are vascular physicians as well because we have no medical reciprocal as the nephrologist to urologist, neurologist to neurosurgeon, gastroenterologist to abdominal surgeon, and cardiologist to cardiac surgeon. Most emphatically, we do not require our patients to be “cleared for surgery” but collaborative consultation may occasionally be required. For the most part, however, we can do it all! Consequently, as complete physician-surgeons we have the great privilege and opportunity to express our humanism to patients. Therefore we must emphasize humanism at all levels of training. We must serve as role models of humanism so that our students, residents, and fellows will not be obsessed with technology and computer printouts to the neglect of the patient, as recently chronicled by the late Dr. Leslie E. Rudolph in his presidential address to the Southeastern Surgical Congress.27Rudolf LE. Surgical humanism.Am Surg. 1991; 57: 1-3PubMed Google Scholar It is regrettable that some surgical specialists have abrogated their humanistic responsibilities by allowing alleged “cognitivist” colleagues to manage most of the patient's care and virtually “draw the dotted line” on which the surgeon should cut and to which he should be restricted. Vascular surgery is and must remain a “body contact sport.” Touching, listening, being compassionate, and even being philosophical and metaphysical about illness so that we are not perceived as cold-hearted technocrats will help restore humanism to surgical care. Humanism is the glue that binds the art to the science of surgery, it is the essence of surgery. It not only binds us closer to our patients but our students, residents, colleagues, and families as well. Humanism makes us more compassionate and instills humility and helps us not to take ourselves so seriously. Vascular surgeons, because we are physician and surgeon in one, have a mandate to provide leadership and serve as humanistic role models. We must reaffirm and rededicate ourselves to humanistic medicine and become a trinity of physician-surgeon-humanist (Fig. 1).More than 60 years ago, Dr. Francis W. Peabody, a scientist who established the Thorndike Memorial Research Laboratory at the Boston City Hospital, noted, “One of the essential qualifies of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”28Peabody FW. The care of the patient.JAMA. 1927; 88: 877-882Crossref Scopus (595) Google Scholar Peabody also warned that scientific progress would erode the importance of humanism. And it may have. Our challenge is to reverse this perception and instill both humanism and scientific investigation into our training programs at the earliest possible opportunity. Vascular surgery is uniquely qualified to fulfill this obligation to society. Are humanism and technological advances through research mutually exclusive? Absolutely not! Humanism and commitment to the patient to cure his disease, because he is a human being to whom the physician is inexorably bonded, stimulates creative thinking. Humanism was the stimulus for the development of the heart-lung machine by one of our past presidents, Dr. John H. Gibbon, Jr. It is clear that a strong connection exists between humanism and scientific research driven by humanistic concern and commitment to the patient. The Society for Vascular Surgery was inseminated during a meeting of the Southern Surgical Association in Hot Springs, Va., on Dec. 5, 1945, when Dr. Ross Veal met with Drs. Arthur Allen, Isaac Bigger, Arthur Blakemoore, Barney Brooks, Mims Gage, and George Lilly. This informal discussion culminated in an organizational conference held in San Francisco on July 3, 1946, at which time the Society for Vascular Surgery was born. The first annual meeting took place on June 8, 1947, in Atlantic City. Dr. Geza de Takats who was the recorder of the new society, listed as the first objective, “To promote research and study in vascular disease.” Consequently, 44 years ago, almost to this day, the need was recognized to promote research and provide a forum for surgeon-scientists to report their research findings on vascular diseases. Advancing our discipline and providing a lasting legacy for our patients and those vascular surgeons yet to come can only be assured through research, either clinical or bench. Without such initiatives, vascular surgery, will cease to exist. Vascular surgeon-scientists are best able to bridge the gap between bench research and pragmatic clinical applications of such research. Clinical research also is absolutely essential to provide answers that come only from studying the human animal. To this end, leadership and participation in well designed randomized clinical trials must be encouraged. The Society for Vascular Surgery has already provided leadership in clinical investigation by establishment of the Randomized Clinical Trials Committee and the Committee on Reporting Standards for clinical investigations. However, beyond establishment of committees and moral support for research by the Society for Vascular Surgery, something more tangible is required. To maintain and increase vascular surgery's cutting edge in research, our long-term commitment and obligation to society, it is essential that young surgeon-scientists be nurtured. We must heed Dr. Owen H. Wangensteen's admonition to the American Surgical Association when he noted, “… For our discipline's continuing advance, surgery needs future Teachers, anxious to create an atmosphere that will encourage research and creative scholarship. …” Unfortunately, vascular surgical research may be in serious jeopardy because the surgeon-scientist is becoming extinct as a result of an inadequate nurturing milieu. Reflecting this lack of nurturing of surgeon-scientists is the decrease in the number of MD-postdoctoral traineeships and fellowships awarded by the National Heart Lung and Blood Institute (NHLBI) since 1965.30Fredrickson DS. Biomedical research in the 1980's.N Engl J Med. 1986; 304: 509-517Crossref Scopus (30) Google Scholar Furthermore, this decline continues. Only 20 of 70 applicants in the physician-scientist category received funded research career awards in 1989.31Circulation. 1990; 82: 1549-1559Crossref PubMed Scopus (2) Google Scholar That only 20 such individuals were identified, nationwide, is both discouraging and alarming. These trends are ominous and must be reversed by developing strategies and mechanisms to enhance funding for research-training and development, because decline in research awards to physician-scientists will most assuredly hasten the extinction of this endangered species. 32Healy B. The human factor at the endless frontier.Circulation. 1989; 79: 959-965Crossref PubMed Scopus (3) Google Scholar, 33Wyngaarden JB. The clinical investigator as an endangered species.N Engl J Med. 1979; 301: 1254-1259Crossref PubMed Scopus (408) Google Scholar Indebtedness of our young medical school graduates deters pursuit of an academic career thereby decreasing the pool of potential surgeon-scientists. In 1988, 83.4% of all medical school graduates had some indebtedness which averaged more than $38,000.34Taskel L Jolly P Beran R. US medical school finances.JAMA. 1989; 262: 1020-1028Crossref PubMed Scopus (6) Google Scholar More than $50,000 was owed by 24% of graduates, and it has been documented that most defer payment until after training.35Hernried J Binder L Hernried P. Effect of loan indebtedness and repayment on resident physician's cash flow.JAMA. 1990; 263: 1102-1105Crossref PubMed Scopus (15) Google Scholar To students and residents so encumbered by debt, private practice beckons with its perceived economic advantages. Student-resident indebtedness and an NIH budget maintaining the status-quo portend serious consequences for the future of vascular surgeon-scientists. These developments also adversely affect industry by shifting potential MD-scientists to law and business careers and decreasing the innovative ideas that generate patents, as has occurred in prosthetic vascular graft development. It is clear that a Lifeline is needed to reverse this trend. We must not depend only on one source for funding and nurturing young surgical investigators. Dr. Allan Callow emphasized this in his 1986 presidential address when he suggested that other avenues for funding must be sought since our present system of funding biomedical research appears tenuous.13Callow AD. Presidential address: the microcosm of the arterial wall—a plea for research.J Vasc Surg. 1987; 5: 1-18PubMed Scopus (22) Google Scholar Alternative and additional funding sources will provide training to the surgeon-scientist who desires to make a commitment to research. It will also enhance his ability to compete with PhDs for limited federal funds. In addition, we must try to influence NIH administrative policies so they are modified to facilitate cofunding from other sources and to provide funding from more than one source for separate, nonoverlapping aspects of the same research project. To this end, philanthropic foundations have been established to supplement and often substitute for lack of societal responsibility to nurture clinician-scientists. The Mosley Funds of Harvard, the Kirby Funds at Penn, and the Fund for Henry Ford Hospital are examples of institutional sources of support. On a more global scale are the Fulbright Awards and the now phased out Markle Scholar Program. The American College of Surgeons and the American Heart Association also address these needs. Numerous surgical specialty societies also have developed foundations to nurture surgical-scholars and collectively provide awards totaling approximately $550,000 per year.36American College of Surgeons surgical research and education committee survey Bull Am Coil Surg. 1991; 76: 31-33Google Scholar Included among surgical society funding agencies with annual dollars allocated are the American College of Surgeons ($100,000), American Society of Colon and Rectal Surgeons ($90,000), American Association of Neurological Surgeons ($87,500), American Society of Transplant Surgeons ($45,000), American Surgical Association ($35,000), American Association for the Surgery of Trauma ($35,000), and the Surgical Infection Society (535,000) to name a few. The Society for Vascular Surgery has been conspicuous by its absence among t
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