Online Health Chat with Leann Olansky, MD, and Vineeth Mohan, MD
November 12, 2014
Life doesn’t stop just because you have diabetes. Beyond handling the immediate changes in diet, exercise and insulin, you need to consider everyday life events that may also be affected by the diagnosis of diabetes. “Managing Diabetes in the Real World” is your chance to chat with Cleveland Clinic diabetes experts, Dr. Leann Olansky and Dr. Vineeth Mohan about diabetes topics that books or websites may not address.
- What do you have to consider when you’re thinking about getting a body piercing or a tattoo?
- How do you determine how much alcohol you can drink without it affecting your diabetes?
- If you’re interested in menopause-related hormone replacement therapy, what do you need to watch out for?
- When do you tell that new person in your life that you have diabetes?
- What do you do when the allergy medications you can’t live without seem to be affecting your blood sugar?
- How do you deal with your insulin pump and sex?
- Which cosmetics, lotions and shaving creams should you avoid?
In addition to these types of questions, you also can ask our experts about aspects of diabetes and nutrition, exercise, medication and treatment options.
About the Speakers
Leann Olansky, MD, is a Staff Physician with the Department of Endocrinology based on the Main Campus of Cleveland in Cleveland, Ohio. Dr. Olansky is board-certified in the subspecialty of endocrinology, diabetes and metabolism by the American Board of Internal Medicine. She sees patients at the Cleveland Clinic Stephanie Tubbs Jones Health Center in East Cleveland. Dr. Olansky's particular interests include Type 1 and Type 2 diabetes, diabetes complications and glucose sensing technology for management of diabetes. She was appointed to Cleveland Clinic in 2006.
Dr. Olansky received her medical degree from Emory University in Atlanta. She completed her residency with Georgetown University and a fellowship with the University of Virginia Medical Center. She is a Fellow with the American College of Endocrinology and the American College of Physicians. She is a member of the American Diabetes Association, the Endocrine Society, the American Association of Clinical Endocrinology, the American College of Physicians and the American Society for Bone and Mineral Research.
Vineeth Mohan, MD, is an endocrinologist in the Department of Endocrinology at Cleveland Clinic Florida. He is board-certified by the American Board of Internal Medicine with a subspecialty in Endocrinology. Dr. Mohan received his medical degree from the University of Texas Southwestern Medical School. He completed his residency at Wilford Hall Medical Center and a fellowship in endocrinology at the National Capital Consortium at Walter Reed Army Medical and National Naval Medical Centers. His specialty interests include general endocrinology, thyroid disorders, parathyroid disorders and diabetes.
Let’s Chat About Diabetes
Moderator: Welcome to our chat today with Cleveland Clinic endocrinologists, Dr. Leann Olansky in Cleveland and Dr. Vineeth Mohan in Florida. We are thrilled to have both speakers available to share their knowledge and expertise about managing diabetes in the real world.
Let's get started with our questions...
LucyintheSkies: How much are diabetes and genetics related? My dad was overweight, did not exercise, had a terrible diet and ended up with adult-onset diabetes progressing to insulin-dependent. I am 58 and wondering if I do everything right with diet, exercise, etc., is there still any chance that I may get diabetes? I just don't know if there is any way to totally prevent diabetes.
Leann_Olansky,_MD: Genetics has a lot to do with developing diabetes, but environment has a lot to do with it as well. This means that you adopt a healthy lifestyle that leads to near normal weight (healthy diet and moderate exercise – 150 minutes per week). This doesn't guarantee that you won't get diabetes, but it decreases your risk. This has been shown in the Diabetes Prevention Trial in people who have pre-diabetes. The earlier you start, the more likely you are to delay or prevent the onset of Type 2 diabetes.
occupant16365: How much of an impact can stress make on your blood sugars?
Leann_Olansky,_MD: Stress can have a huge impact on managing your diabetes on a daily basis. Generally, it makes blood sugars go up. In some Type 1 diabetics, the blood sugar can trend low. If you are under stress, it is even more important to check blood sugars regularly and more frequently than normal.
Ale8_lover: I am a new diabetic and I exercise a lot! Are there any specific exercises or precautions I should take into account?
Leann_Olansky,_MD: Exercise will help lower your blood sugar and lower your insulin requirements. You should be checking your blood sugars before and after you exercise. If you are on insulin or a sulfonylurea agent that stimulates insulin, you may have a low blood sugar before or after exercise. Most drugs for Type 2 diabetes other than sulfonylureas should not cause hypoglycemia. Exercise will make your drugs for diabetes be more effective. Go for it!
occupant16365: What range should your blood sugar be to require a snack before exercising?
Leann_Olansky,_MD: If your blood sugar is less than 120, you should probably have a snack. Fifteen to 30 grams of carbs should be sufficient for moderate exercise. If exercise will be more intense, you may need a higher target of 150 to 180. If you are starting a new exercise regimen, please test before during and after until you figure out your glucose response to that exercise.
Diabetes and lifestyle
snA252: I have diabetes. Is there any risk of getting a tattoo?
Leann_Olansky,_MD: As long as the tattoo artist uses sterile equipment and ink, and your blood glucose is controlled, you are not at any more risk than a non-diabetic person. The main risk is for infection. Be sure you are certain of what it says, as tattoos are forever.
Susan: I have diabetes (insulin-dependent). Can I breastfeed?
Leann_Olansky,_MD: Yes you can. It is good for the baby and for you. However, you may require lower dosages of insulin.
rtayek: What are the advantages and disadvantages of using a glucose pump?
Leann_Olansky,_MD: You probably mean an insulin pump. This is the best way to deliver insulin for those with Type 1 diabetes or Type 2 that requires multiple doses of insulin. It uses one type of short-acting insulin. It allows you to increase insulin if blood sugar is high or suspend the infusion temporarily if sugar is trending low. You can lower the rate for exercise to prevent hypoglycemia.
The disadvantage is a pump is more expensive, at least initially. If there is a kink in the tubing or a pump malfunction, blood sugars can rise quickly. Some people do not like the idea of having a device connected to them at all times.
Mr Pibbs: What about having an insulin pump and sex? What do you do about that?
Vineeth_Mohan,_MD: Pumps with tubing can be disconnected during sexual activity, which would leave the person unencumbered. Patch/pod-style pumps have no tubing/catheters and are worn during sexual activity. There is the potential for such a pump to get dislodged if it is struck, so the exact place it has been applied to the skin should be taken into consideration. Just like any form of physical activity, sex can result in a lowering of blood sugar. This should be kept in mind with consideration for blood sugar monitoring before/after activity or when having symptomatic low sugar.
verdun: Can I go for hair waxing if I have diabetes? Does it depend on the type of diabetes you have?
Leann_Olansky,_MD: It does not matter what kind of diabetes you have, but be careful you don't get burned by the hot wax. Healing may be delay if you have diabetes.
Claudine: Do you have any recommendations about whether or not to have pedicures? I would think it is good for diabetes in regards to foot health, but are there precautions that I should look out for?
Leann_Olansky,_MD: Just as it is with tattoos, it all depends on the technician using sterile equipment. It is probably better to have pedicures than to try to do it yourself, and the professionals have a better view and better access than you have to your toenails. Again the professions should not produce any cuts to the skin. You should not be bleeding.
Sobon: Are there precautions to take with my gardening, like dealing with different soils, fertilizers etc.?
Leann_Olansky,_MD: You have to realize that there are bacteria in the soil and on the plants. I would use gloves and protect your legs from scratches. Otherwise, there is no problem.
comet: At what point (1AC, etc.) do you "panic," and what do you do if everything has failed?
Vineeth_Mohan,_MD: Emergent evaluation of high blood sugar is needed (i.e. a visit to an ER) when blood sugars are severely elevated (e.g. > 350 to 400 range) and not coming down with treatment and with associated severe symptoms (such as nausea/vomiting, lightheadedness, etc.). Chronically high blood sugar causes problems by increasing the risk of long-term complications. It should be controlled, but usually there's no need to "panic" in this situation. I generally begin to consider more aggressive therapies, such as insulin, once A1Cs are in the "double digit" range. Insulin may also be needed for those with lower A1Cs when combinations of non-insulin drugs are ineffective. Fortunately, adequate amounts of insulin will always work to bring down blood sugar, though the right types and the right doses must be administered at the right time!
ccligal: I am a well-maintained D2 senior. I take metformin 1000 2x/day. My A1C is below 7, often low 6. I am 100 lbs. overweight. I exercise (lap swim) 30 minutes at least/day plus sometimes one to two-mile/walk per day. I have proteinuria and fatty liver. BUT I HAVE NOT BEEN ABLE TO LOSE WEIGHT. Every nutritionist consulted says something along the lines of "Oh, that's a tough one" if they are even familiar with proteinuria. I need ideas.
Vineeth_Mohan,_MD: Losing weight and maintaining the weight loss are major challenges for most people. Our bodies are remarkably efficient and designed to store energy in the form of body fat as an important protective mechanism. Unfortunately, this "backfires" in the modern age. Although exercise has proven cardiovascular benefits and can prevent weight gain, its impact on producing weight loss is usually minimal (unless there's sustained and highly strenuous exercise involved). Dietary efforts have a much greater impact on weight loss. I'd recommend strict caloric monitoring with the use of calorie-tracking apps available for most smartphones, eating breakfast daily and daily weighing. Preparing your own meals ahead of time may be helpful for portion control. Checking your thyroid function is reasonable. Rarely do we find an underlying disease state producing weight gain, but we consider this if there are other signs/symptoms of various rare disease. Bariatric surgery such as gastric sleeve or gastric bypass is highly effective at reducing body weight and controlling diabetes for those unable to lose weight by other means.
Ken Westra: Does metformin maintain effectiveness over the long haul, I mean using it for several years? For the last four years, I have maintained an A1C in the low 5s (it was 9 plus when diabetes was discovered). Originally, glipizide was also prescribed but the two drugs working together gave me daily readings in the high 90s and hypoglycemia was a constant threat, so I stopped glipizide. It took a while to adjust to metformin, (made a mess of digestive issues), but now I feel comfortable with it and hope a new medication will not be in the future.
Vineeth_Mohan,_MD: Metformin will continue to work as an insulin sensitizer (it improves how well insulin works in your body, thereby reducing sugar). Unfortunately, the disease of diabetes itself is a progressive one characterized by gradual loss of insulin production by the pancreas. This progression tends to result in higher blood sugars over the years, even when diet/exercise/weight/drug therapy is stable. The rise in sugar may be misinterpreted as the medication "not working," but is actually the result of diabetes progressing. This is why combinations of medications are often needed over the years. As long as you're doing well with metformin and tolerating it well, it should be continued.
crisispro: Are there general categories of over-the-counter medicines that should be avoided by diabetics?
Vineeth_Mohan,_MD: Some cough and cold items have sugar-based syrups, which should be avoided. Alternatives to these are often advertised as "sugar-free," which should be OK. Additionally, some medications for cough/cold have ingredients that may elevate blood pressure. Patients with diabetes commonly have problems with high blood pressure, and such items should be avoided. Please consult with a pharmacist if you have questions regarding a specific product with regard to its potential to raise blood sugar or blood pressure.
sam500016: Hi. I am diabetic, Type 2, since January 2006. I live in India .I am presently managing glycemic control with 2x 850 mg of metformin and 0.5 mg of Voglibose before dinner. (Voglibose is like Precose®). My main issue has been post-supper spikes. Everything was okay until about a month ago, when my post-supper BG hit 260 and FBG 135. What should I do? My doctor wants me to try Jalra (vildagliptin) but I am scared of the side effects. Is it safe? Would it be best to go on insulin, as it is safest? I would be thankful for advice on a future course of action. Regards, Sam500016
Leann_Olansky,_MD: Vildagliptin is in the class of DPP-4 inhibitors, and these drugs are very safe. It will not put you at risk for hypoglycemia and, therefore, is safer than insulin. Also, it will not tend to increase weight, as insulin would. I think you should try it.
yankie: I have an A1C of 9. I know it's way too high. I take all the medications prescribed by my physician. What can I do? Why doesn't the medication get my sugar under control? Also, it seems that when I lower my sugar, my weight goes up. Can you explain what causes me to gain weight if my sugar level decreases? Thank you!
Vineeth_Mohan,_MD: Whenever A1C/sugars are elevated above goal, some intervention should be done to improve it. Sometimes, the intervention is related to diet/exercise and sometimes it is related to an increase in the dose or number of diabetes medications or a combination of both. Each drug we have (apart from insulin) has the capacity to lower A1C by about 1 to 1.5 percent at the most, so many patients will require combinations of medications to achieve goal A1C. For example, if you have an A1C of 9 percent on a single drug, you would likely need TWO additional drugs to get under 7 percent if your diet/exercise regimen remains constant. When the goals cannot be controlled with combinations of oral medications, insulin is often considered. Fortunately, insulin can achieve excellent control of blood sugar if delivered appropriately.
Some drugs for diabetes are associated with weight gain, some are weight-neutral and others can produce some weight loss. Those associated with weight loss are called GLP-1 agonists (injectables) and SGLT-2 inhibitors (orals). When blood sugar is severely elevated (e.g. > 200 range), we begin to see glucose eliminated from the body into the urine. This means that a patient with uncontrolled diabetes might have a tendency to lose weight (due to loss of calories in the urine in the form of sugar). When blood sugar is better controlled, there is a risk for weight gain (even when diet is stable) since fewer calories are eliminated in the urine. Increasing attention to diet/exercise as the blood sugar improves may "counter" this tendency.
rtayek: I have recently been diagnosed with Type 1 diabetes. Is consumption of alcoholic beverages – beer, wine or mixed drinks – strictly prohibited, or is there a policy I can follow in order to partake?
Vineeth_Mohan,_MD: Alcohol in moderation is compatible with Type 1 diabetes. Moderate alcohol consumption is generally defined as one drink/day for women and two drinks/day for men. I would recommend that you avoid heavy consumption to the point of intoxication, as this may make the identification and treatment of hypoglycemia quite difficult. Keep in mind that alcohol does have carbohydrates, which may have a variable impact on blood sugar. Some drinks are mixed with juice, which will have a more significant impact on blood sugar.
crisispro: What are some good snacks to eat before exercise?
Leann_Olansky,_MD: One to two servings of carbs are recommended depending on the type of exercise you are doing. Examples would be yogurt, a piece of fruit or granola bar, and whole-grain bread or crackers with peanut butter. If you are on insulin, be sure to carry glucose tablets or some hard candy in case you have a low blood sugar level despite the snack.
touche: Please explain the significance of A1C. I just don't get it.
Leann_Olansky,_MD: Glucose attaches to proteins in proportion to how high the glucose is and how long the protein is exposed to the blood. Hemoglobin usually has a very consistent duration, as the red blood cells are replenished every 120 days. This allows us to gauge what the average blood sugar has been for the previous three months. Therefore, we can tell, on average, how well the blood sugar has been controlled. Studies of diabetes control and complications show that lower A1Cs are associated with less severe complications. That is why your doctor wants it to be below 7 percent unless you are at high risk for hypoglycemia. Does that help?
crisispro: I understand that getting A1C too low is just as dangerous for diabetics as having it over 7.0. How low is considered appropriate?
Vineeth_Mohan,_MD: We worry mainly about A1Cs being "too low" when this is associated with frequent hypoglycemia. For example, a person with an A1C of 5.7 percent who has frequent hypoglycemic reactions is not well-controlled and risks serious complications related to low blood sugar. Additionally, a person who has an A1C of 5.7 percent on multiple drugs but without hypoglycemia would likely do just as well with fewer drugs and an A1C slightly higher (e.g. < 6.5 percent). Since each drug carries its own side-effect profile, sometimes "less is more!"
crisispro: For diabetics, is the goal of A1C to be as close to 6.0 or just to keep it under 7.0? Mine stays between 6.4 and 6.7, and my doc doesn't want to see it lower than about 6.4. Is this in keeping with current practice?
Vineeth_Mohan,_MD: In the past, we often used a specified A1C target as a goal for all/most people with diabetes. The American Diabetes Association traditionally used the target of < 7 percent while the American Association of Clinical Endocrinologists advocated a more aggressive target of < 6.5 percent. More recently, we have realized that a "one size fits all" approach is not reasonable, and flexible A1C targets should be applied with consideration for multiple patient factors. In general, higher A1Cs are acceptable for individuals who are older (e.g. 65-70+), who already have multiple severe medical problems/complications or who are at risk for severe hypoglycemia. Younger individuals who are otherwise in good health and in whom severe hypoglycemia is not a major threat should be treated more aggressively to a target of < 6.5 percent in most cases. The benefits of pushing the A1C closer into the normal territory compared with a value of <6.5 percent would likely be minimal, especially if this requires a multi-drug regimen or insulin to achieve.
Jn234QZ: Would you explain neuropathy and if it can be prevented?
Leann_Olansky,_MD: Neuropathy is nerve damage. High glucose damages the nerves, so keeping it as close to normal is the best protection. High triglycerides have also been seen to cause nerve damage, so if you have high triglycerides, fibric acids (drugs that lower triglycerides) can protect as well.
14petluver: What suggestions do you have to regulate my currently out-of-control blood glucose levels when my diagnosis of hyperadrenergic POTS causes severe side effects on all but one oral medication my doctor has tried so far, and the Januvia® 100 mg is no longer enough to control the levels:
Metformin - Severe nausea, not able to function in daily life (on disability)
Farxiga™ - Severe hypotension
Starlix® - Severe hypotension
Does Cleveland Clinic have a team approach to working with patients like me with multiple health issues?
Leann_Olansky,_MD: Try an alphaglucosidase inhibitor such as acarbose or miglitol with Januvia. You can substitute Januvia for a GLP1 agonist such as Victoza®, Bydureon®, Tanzeum™ or Trulicity™. Cleveland Clinic does have interdisciplinary teams to help manage complex problems such as yours.
comet: Can neuropathy be reversed?
Vineeth_Mohan,_MD: The symptoms of neuropathy (such as burning pain, tingling, "pins and needles") can be reversed with better blood sugar control. Additionally, drugs that specifically target neuropathy (such as gabapentin and others) will also "reverse" these symptoms. Unfortunately, loss of nerve function resulting in complete numbness to the area cannot yet be reversed. Patients who have numbness in their extremities lose an important protective mechanism (i.e. they don't feel when they have an injury in the area) and are at risk for complications such as foot ulcers.
sinaihospital: I have had Type 2 diabetes since 2010. I also have high blood pressure and high cholesterol. Is there a link to heart disease, yes or no? I also have hypertensive heart disease. I am only 49 years old and take two diabetes medicines for it. My doctors say I am at risk for problems like PAD (peripheral artery disease) and vision problems. What doctor should I see for my Type 2 diabetes? How often must my eyes be examined by an eye doctor since I have Type 2 diabetes? Thank you.
Vineeth_Mohan,_MD: Diabetes is associated with an increased risk of cardiovascular disease, which includes coronary artery disease and peripheral artery disease. Fortunately, through management of blood pressure, cholesterol and blood sugar, your risk for heart-related events can substantially drop. Of these, blood pressure and cholesterol management appear to be more important than blood sugar control (with respect to cardiovascular disease). It is generally recommended that most patients with diabetes in your age group should be on statin-class drugs (types of cholesterol drugs) that are known to reduce the risk of cardiovascular disease. Eye exams are recommended annually for most patients. Blood sugar control has the greatest impact in reducing the risk of diabetes-related eye disease. Most patients with diabetes Type 2 are followed by primary care physicians (such as internists and family physicians). Those with more complex issues may need to be referred to an endocrinologist.
Jopasas: What other autoimmune disorders tend to occur along with diabetes?
Vineeth_Mohan,_MD: Type 1 diabetes is an autoimmune disorder, which can be associated with other forms of autoimmune conditions. Fortunately, most people with Type 1 diabetes will only have this issue. However, other autoimmune disorders to consider include:
Hypo- and hyperthyroidism (fairly common in association)
Celiac disease (more common than previously recognized)
Others include vitiligo, rheumatoid arthritis, lupus, Addison's disease and others
We usually screen for thyroid disease in all patients with Type 1 diabetes, and screening for celiac disease is recommended by some physicians.
crisispro: Please provide an update on research into an artificial pancreas. How soon are we likely to see one in use for significant numbers of patients?
Vineeth_Mohan,_MD: There's tremendous interest in the development of the artificial pancreas. The latest step forward was earlier this year when researchers demonstrated good control of blood sugar in patients on such a device in a "real world" setting. Prior studies all took place in a laboratory setting. Larger scale studies will need to be done before such devices become available for general use. It will likely take several years for such a device to become available.
Currently, there is an insulin pump that communicates with a continuous glucose sensor that is available on a limited basis. This pump "shuts off" when the sensor detects severe hypoglycemia.
crisispro: What does the latest research show regarding maintaining acceptable glucose levels for diabetics and the risk of neuropathy, blindness, etc.? Which is to say, if my diabetes remains under good management, how likely is it that I will develop any of those scary effects? FYI, I am Type 1.5. (I lost half my pancreas to Whipple but am also not utilizing the existing insulin well. I am on metformin, glimpiride and 11 mg Lantus® at night.)
Leann_Olansky,_MD: Individuals vary with how sensitive they are to elevated glucose levels, but generally, an HBA1c of 7 percent or less has a low risk for advancing complications if you do not already have neuropathy, retinopathy and chronic kidney disease. For kidney disease, control of blood pressure is also a very important preventive measure to limit your risk for developing chronic kidney disease.
crisispro: What is the latest research on long-term use of statins and their side effects? I have been on statins for years, even before I became diabetic, due to a strong family history of heart disease (and diabetes), but I have several friends who have disorders (one who's had a heart attack and one with very high cholesterol).
Vineeth_Mohan,_MD: Statins in general have an excellent and long safety track record. These drugs are typically prescribed long-term and have a proven impact on cardiovascular risk reduction. The most common side effect remains muscle-related, to include muscle pain/weakness or (rarely) more severe muscle damage. Liver-related side effects of statins appear to be over-stated, as severe liver injury from these drugs is a remote possibility. More recently, there has been a link between statins and higher blood sugars. This does not happen for most and is typically mild if it occurs. Still, the cardiovascular benefits outweigh this issue. Finally, a rare group of patients may have reversible memory loss on statins, which goes away once the drug is discontinued. I am not aware of any issues tied to the length of therapy with statins (most side-effects occur soon into treatment).
comet: How close are we to a cure for diabetes?
Leann_Olansky,_MD: There is constant research in understanding the causes of Type 1 and Type 2 diabetes. A cure for Type 1 is probably different from Type 2 diabetes. For Type 2 diabetes, prevention is probably going to be the main way of reducing it. For Type 1 diabetes, it will be some type of replacement therapy, either an artificial pancreas (insulin pump and sensor that adjusts insulin to glucose levels) or islet cell transplantation.
lmasarik: Are there any resources you could recommend of where to ask “everyday questions” beyond this chat, maybe a good online group or network? There are questions that maybe don't need to be answered by a doctor, but there is so much info out there it's hard to muddle through it, and sometimes it's difficult to talk to family that doesn't always understand.
Leann_Olansky,_MD: Check in your local community for diabetes educators or support groups. Check the American Diabetes Association online or clevelandclinic.org/diabetes for more information.
ccligal: What is the maximum age bariatric surgery will be performed? I'm not that ancient but want to gauge how much time I have before the surgical window closes.
Leann_Olansky,_MD: Each facility that does these surgeries likely has its own guidelines. Also, it depends on how healthy you are. Contact the individual program for specific information.
Ken Westra: How significant is the expiration date on test strips?
Vineeth_Mohan,_MD: I would generally advise using test strips before the expiration date. These items do degrade over time and in response to humidity and heat. This may result in mis-dosing of medication, especially if you're on insulin. Control solutions for these strips are available to check their accuracy.
Moderator: I am sorry to say that our time with Dr. Olansky and Dr. Mohan is now over. Thank you, doctors, for sharing your expertise and your time with us today to answer some important questions about managing diabetes.
Leann_Olansky,_MD: I hope this chat session has been helpful. Remember, when it comes to diabetes management, the patient is an important member of the team, the most important member, as there is little the rest of the team can do if the patient is not onboard and engaged. We welcome well-informed patients, and I am happy you are seeking more information. Thanks for asking great questions.
Vineeth_Mohan,_MD: It has been a pleasure to participate in this web chat. I do hope this has been informative. I am hearted by the interest in diabetes by the patients here. I do believe that this is a condition in which self-management and life-long learning go a long way toward avoiding complications. Wishing you all the best.
To make an appointment with Dr. Olansky in Cleveland or to find an endocrinologist/diabetes specialists for your needs, contact the Endocrinology & Metabolism Institute at 216.444.6568 (or toll-free 1.800.223.2273, ext. 46568). To make an appointment with Dr. Mohan in Florida or any of the other specialists in Endocrinology, Diabetes & Metabolism at Cleveland Clinic Florida, please call 877.463.2010. You can also visit us online at clevelandclinicflorida.org.
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