hemolytic anemia and a1c

Home BMJ Case Rep. 2013 Aug 8;2013:bcr2013200307. Another condition that affects hemoglobin A1c levels is anemia. Signs and symptoms of drug-induced hemolytic anemia are similar to other forms of hemolytic anemia. / afp Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. A1c reflects average blood sugars over 2 to 3 months, and through studies like DCCT and UKPDS, higher A1c levels have been shown to be associated with the risk of certain diabetes complications (eye, kidney, and nerve disease). Evidence of a threshold value of glycated hemoglobin to improve the course of renal function in type 2 diabetes with typical diabetic glomerulopathy. Hemolytic anemia is any kind of anemia that destroys the red blood cells, as this reduces the lifespan of the cells and hence results in abnormally low A1cs. Thus, HbA1C may be a screening test for hemolysis in non-diabetic patients with hemolytic anemia, but in diabetic population with hemolytic disease it is considered to be a very poor marker for both, overall glycemia and haemolysis. [Clinical features and laboratory data analysis of decreased glycosylated hemoglobin related to hemolytic disease]. Hemoglobin A1c (“HbA1c” or just “A1c”) is the standard for measuring blood sugar management in people with diabetes. This difference was statistically significant (p0.02). 2007 Nov;29(11):2349-64. doi: 10.1016/j.clinthera.2007.11.016. 7(April 1, 2005) Acquired hemolytic anemia is not something you are born with. 6. doi: 10.1136/bcr-2013-200307. You develop the condition later. Want to use this article elsewhere? It reflects the average amount of … Mealtime 50/50 basal + prandial insulin analogue mixture with a basal insulin analogue, both plus metformin, in the achievement of target HbA1c and pre- and postprandial blood glucose levels in patients with type 2 diabetes: a multinational, 24-week, randomized, open-label, parallel-group comparison. Case presented involves a 72-year-old patient with history of diabetes and possible iatrogenic-induced autoimmune hemolytic anemia. A new unstable hemoglobin (Hb) variant, named Hb Aalesund, was detected during Hb A1c measurement in a patient with a nearly compensated hemolytic anemia. And although iron-deficiency anemia makes the A1c go up, hemolytic anemias make the A1c go down. [1,13] In patients homozygous for a variant hemoglobin, such as patients with sickle cell anemia or hemoglobin C disease, … Immediate, unlimited access to all AFP content. Despite A1C values as low as 3.9 percent, she denied having hypoglycemic symptoms and reported self-monitored blood glucose measurements of 108 to 144 mg per dL (6 to 8 mmol per L) while fasting and a postprandial value of less than 162 mg per dL (9 mmol per L). Murad F. Immunohemolytic anemia during therapy with methyldopa. This site needs JavaScript to work properly. Clipboard, Search History, and several other advanced features are temporarily unavailable. The HbA1c results are used to provide an estimation of the patient’s glycemic control over the last two to three months, assuming the RBCs have an average circulating lifespan of 120 days. In my practice, about 30-40% of my patients have some degree of anemia, so this is not an uncommon problem. The dosage was increased to 1 g per day over the previous 10 months. Fatigue, t… Lancet 1966;2:133-5. Methyldopa-induced autoantibodies against red blood cells. Pruss A, Salama A, Ahrens N, Hansen A, Kiesewetter H, Koscielny J, Dorner T. Immune hemolysis–serological and clinical aspects. LoBuglio AF, Jandl JH. Specimens from patients with polycythemia or postsplenectomy may exhibit increased HBA1c values due to a somewhat longer lifespan of the erythrocytes. Methyldopa-induced autoimmune hemolytic anemia is a recognized cause of warm-antibody immune hemolysis.1-3 Formation of red-cell autoantibodies has been observed in up to 10 to 20 percent of patients receiving methyldopa therapy.4,5 Presumably, alpha-methyldopa alters antigens on red blood cells and makes the proteins of the cell membrane Rhesus complex immunogenic, leading to the formation of red-cell antibodies. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. This series is coordinated by Kenny Lin, MD, MPH, Associate Deputy Editor for AFP Online. People who are anemic have short-lived red blood cells, so like diabetics, they will test with falsely low A1c levels. Clin Exp Med 2003;3:55-64. As the lifespan of erythrocytes is normal in sickle-cell trait, selection of an appropriate assay should produce valid HbA1c results. N Engl J Med 1967;276:658-65. HbA1c reflects the average blood glucose levels in the previous 2–3 months 2, and is a more convenient measurement than fasting plasma glucose, as it does not require fasting. With decreased erythropoiesis such as with iron deficiency anemia increased mean age of red blood cells increases hemoglobin A-1 C levels. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors. Brocco E, Velussi M, Cernigoi AM, Abaterusso C, Bruseghin M, Carraro A, Sambataro M, Piarulli F, Sfriso A, Nosadini R. J Assoc Physicians India. An elevated reticulocyte count (19 percent) and characteristic features of anemia, polychromasia, and spherocytosis were evident. The current recommendation for glycemic control based on HbA1c values has been widely accepted. Incidence of a positive direct coombs test in patients on alpha-methyldopa. Autoimmune hemolytic anemia, or AIHA, is a rare type of anemia.When you have anemia, your bone marrow doesn't make enough red blood cells.Or these cells don't work as well as they should. 4. Can your a1c be wrong? Immeasurable glycosylated haemoglobin: a marker for severe haemolysis. Robbins DC, Beisswenger PJ, Ceriello A, Goldberg RB, Moses RG, Pagkalos EM, Milicevic Z, Jones CA, Sarwat S, Tan MH. • The apparently healthy patient was subsequently diagnosed with hemolytic anemia, which led to a rapid turnover of red blood cells (RBCs). Hemoglobin A1c (HbA1c) is a glycated hemoglobin formed by the non‐enzymatic attachment of glucose to the N‐terminal valine of the β‐chain of hemoglobin 1. USA.gov. The mean HbA1c for anaemic and non-anaemic groups was 5.35% and 5.74% respectively, amounting to a 0.4 unit difference in (8%) in mean HbA1c. 2016 Oct 28;8(1):e2016058. Even without any pathology present, a 2008 study found that HbA1 c levels vary between hematologically normal individuals based on the heterogeneous range of RBC lifespan. Hemolytic anemia is a disorder in which the red blood cells are destroyed faster than they are made. She required regular insulin therapy for glucose control and was receiving ramipril, methyldopa, and nifedipine for hypertension and diabetic nephropathy. to the editor: I read with interest the article1 on hemolytic anemia by Dr. Dhaliwal and colleagues. In diabetes management, target value is set below 6.5%, to reduce the risk of chronic complications. Hemolytic Anemia Manifesting as Improved A1C Values. All rights Reserved. Possible conflicts of interest must be disclosed at time of submission. Pernicious anemia – an autoimmune disease that impairs the gut’s ability to absorb B12 – is the most common anemia in type 1 diabetes. Murad F. Immunohemolytic anemia during therapy with methyldopa. In cases of hemolytic anemia, the lifetime of erythrocytes is shortened and will result in decreased HBA1c results. NIH For every 1% decrease in A1c, there is … This content is owned by the AAFP. Get Permissions, Access the latest issue of American Family Physician. COVID-19 is an emerging, rapidly evolving situation. Carstairs KC, Breckenridge A, Dollery CT, Worlledge SM.  |  Nonetheless, a dramatic improvement trend of glycemic control over the preceding year was reflected by her recent A1C values. / Vol. afpserv@aafp.org for copyright questions and/or permission requests. Pernicious anemia can be dangerous because it can strain the heart and blood vessels especially hard. [Inappropriate low glycated hemoglobin and hemolysis]. Inherited hemolytic anemia means that parents pass the gene for the condition on to their children. If you have iron-deficiency anemia, your A1C examination results might be falsely high. The A1C test goes by many other names, including glycated hemoglobin, glycosylated hemoglobin, hemoglobin A1C and HbA1c. Glycated hemoglobin A1C reflects a mean glycemia over the preceding 3 months (erythrocyte life span). Conditions such as acute and chronic blood loss, hemolytic anemia, and splenomegaly can … 2005 Apr;53:299-305. N Engl J Med 1967;276:658-65. Case presented involves a 72-year-old patient with history of diabetes and possible iatrogenic-induced autoimmune hemolytic anemia. Hemolytic anemia leads to the reduced lifespan of red blood cells (RBC), and IDA prolongs it; as a result, there occurs the discrepancy in hemoglobin A1c (HbA1c) . Hemolytic anemia, blood loss, pregnancy, and some medications reduce the average red blood cell (RBC) lifespan, leading to reduced HbA1c concentrations . Abnormally low-HbA1c reading can be expected under conditions such as rapid loss of glycemic control [332,333], conditions that decrease erythrocyte lifespan such as hemolytic anemia [325], liver cirrhosis [334,335], hemorrhage, chronic kidney disease [336–339], variant hemoglobin [320,322,340], and hemoglobin in neonates [341,342]. Incidence of a positive direct coombs test in patients on alpha-methyldopa. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. / • Dhaliwal G, Cornett PA, Tierney LM Jr. Hemolytic anemia. Jaundice, yellowing of the skin 2. Previous studies suggest that iron deficiency anemia (IDA) affects the levels of HbA1c. The major form of glycohemoglobin is hemoglobin A1c (HbA1c). When the mean erythrocyte lifespan is decreased such as with hemolytic anemia hemoglobin A-1C is decreased because of the reduced RBC exposure time for glycation. A patient scenario is presented with an A1c in normal range, although this patient’s diabetes was found to be poorly controlled. Also called the hemoglobin A1C, HbA1c, or glycohemoglobin test, the A1C test is based on the addition of glucose to hemoglobin over the typical 120-day life span of … Carstairs KC, Breckenridge A, Dollery CT, Worlledge SM. Pallor, pale coloring of the skin 4. JAMA 1968;203:149-51. JAMA 1968;203:149-51. Occasionally, severe hemolysis ensues in the presence of sufficient antibody production,3 as was the case with our patient. Conditions such as acute and chronic blood loss, hemolytic anemia, and splenomegaly can all cause falsely lowered A1c results. Debard A, Charmion S, Ben Ameur S, Gaultier JB, Cathébras P. Rev Med Interne. The nature of the alpha-methyldopa red-cell antibody. eCollection 2016. This effect will depend upon the severity of the anemia. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. To further highlight the clinical relevance of drug-induced hemolytic anemia, we present an interesting case of hemolysis leading to a diagnostic enigma. HHS The measurement of HbA1C is widely used for the monitoring and management of diabetes mellitus. The interpretation of the A1c test assumes the red blood cells live an average of 120 days. The editors may edit letters to meet style and space requirements. Red blood cells develop in the bone marrow, which is the sponge-like tissue inside your bones. Glyburide/metformin HCl clinical overview. • The shortened RBC life span led to a false low A1c. These symptoms vary slightly based on whether the red blood cell is broken down while in circulation (intravascular hemolysis) or outside the vascular system (predominantly liver and spleen). The prompt reversibility after withdrawal of methyldopa therapy resembles the same phenomenon seen in other autoantibody anemia induced by infectious mechanisms. The A1C test measures the amount of glycated hemoglobin in the blood, which reflects average blood glucose levels over the preceding 3 months. Am Fam Physician 2004;69:2599-606. A normal A1C measurement is less than 5.7%, while people with prediabetes have an A1C measurement of 5.7% to 6.4%, and people with diabetes have an A1C measurement of 6.5% or Factors that affect interpretation of HbA1c Results: Any condition that shortens … Glycated hemoglobin A1c (HbA1c) is an important indicator of glycemic control. Contact A significantly higher variance was observed in the anaemia group (0.79 vs. 0.64). During that time period, glucose in the blood permanently binds to the hemoglobin in the RBC by the Amadori rearrangement forming HbA1c from the wild type (or typical) HbA. Assessment of glycemia in diabetes mellitus: hemoglobin A1c. Autoimmune hemolysis was supported further by the positive direct Coombs’ test, demonstrating the agglutination of the patient’s red blood cells with anti-IgG antisera but not with complement component (anti-C3 sera). Send letters to afplet@aafp.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680. The history of methyldopa therapy in this particular patient made hemolytic anemia a distinct probability, which may have accounted for her “exceedingly good” glycemic control. Clin Exp Med 2003;3:55-64. Methyldopa-induced autoantibodies against red blood cells. 1 - 3 Formation of red-cell autoantibodies has … Murphy WG, Kelton JG. Overview Hemoglobin a1C Normal Value Range Pathophysiology Special considerations Elevated values Decreased values Nursing Points General Normal value 5.6-7.5% Pathophysiology After a prolonged exposure to glucose molecules, HGB binds to glucose RBC life is 90-120 days Blood test measures average amount of HGB bound to glucose Measured as a percentage Goals – <5% for non-diabetics […] Dark (tea or cola-colored) urine 3. Red blood cells have a finite lifespan in the circulation. 3. Murphy WG, Kelton JG. Copyright © 2020 American Academy of Family Physicians. Sign up for the free AFP email table of contents. Zhonghua Xue Ye Xue Za Zhi. HbA1c is the product of the non-enzymatic chemical reaction of Hb with glucose. A 59-year-old woman was evaluated for diabetes mellitus and hypertension in our outpatient clinic. / Journals Your symptoms may include: 1. Interestingly, the "satisfactory" glycemic control index in our patient warned of a shortened red-cell life span, rather than providing a reassuring sign to her physician. The A1C test result reflects your average blood sugar level for the past two to three months. What blood sugar markers are reliable? Methyldopa-induced autoimmune hemolytic anemia is a recognized cause of warm-antibody immune hemolysis. Blood Rev 1988;2:36-42. Artefactually low HbA1C may be associated to conditions with decreased erythrocyte survival, such as hereditary spherocytosis, elliptocytosis, autoimmune or drug-induced hemolytic anemias, and acute or chronic blood. Epub 2008 Nov 18. One of the most severe forms of hemolytic anemia is the kind caused by receiving a red blood cell transfusion of the wrong blood type. 2009 Jun;30(6):525-7. doi: 10.1016/j.revmed.2008.10.010. Dhaliwal G, Cornett PA, Tierney LM Jr. Hemolytic anemia. The nature of the alpha-methyldopa red-cell antibody. Choose a single article, issue, or full-access subscription. 1. 5. Your body normally destroys old or faulty red blood cells in the spleen or other parts of your body through a process called hemolysis.Hemolytic anemia occurs when you have a low number of red blood cells due to too much hemolysis in the body.. Clin Ther. Dapsone therapy for Sweet syndrome was initiated immediately before the reduction in the hemoglobin concentration. NLM The ICET-A Recommendations for the Diagnosis and Management of Disturbances of Glucose Homeostasis in Thalassemia Major Patients. Thus, HbA1C may be a screening test for hemolysis in non-diabetic patients with hemolytic anemia, but in diabetic population with hemolytic disease it is considered to be a very poor marker for both, overall glycemia and haemolysis. In patients with certain hemoglobinopathies and with chemically modified derivatives of Hb, falsely decreased or increased HbA1C results may be found depending on the particular assay meth… Don't miss a single issue. Letters submitted for publication in AFP must not be submitted to any other publication. A: There are several conditions that can affect A1C results because hemoglobin A1C is dependent on both the glucose levels over the last 2 to 3 months and the lifespan of the red blood cell. Please enable it to take advantage of the complete set of features! After discontinuation of methyldopa therapy, the patient’s hemoglobin level increased from 9.1 to 13.3 g per dL (91 to 133 g per L; normal range: 11.5 to 14.3 g per dL [115 to 143 g per L]) over the course of eight weeks, accompanied by decrement of reticulocyte count (from 19 to 4.5 percent) and normalization of plasma haptoglobin concentration (less than 20 to 35 mg per dL [0.20 to 0.35 g per L]; normal range: 33 to 171 mg per dL [0.33 to 1.71 g per dL]). ... 2. Pruss A, Salama A, Ahrens N, Hansen A, Kiesewetter H, Koscielny J, Dorner T. Immune hemolysis–serological and clinical aspects. This is because glucose accumulates on hemoglobin as the red blood cells circulate. doi: 10.4084/MJHID.2016.058. LoBuglio AF, Jandl JH. Every person has a distinct blood type (A, B, AB, or O). Include your complete address, e-mail address, and telephone number. She had taken alpha-methyldopa (250 mg twice daily) for 18 months before the current evaluation. The A1C test is a common blood test used to diagnose type 1 and type 2 diabetes and to monitor how well you're managing your diabetes. Over the past two years, her glycosylated hemoglobin (A1C) values ranged from 6.4 to 8.3 percent (normal range: 5.1 to 6.4 percent) with a stable insulin regimen. To see the full article, log in or purchase access. 3. Am Fam Physician 2004;69:2599-606. De Sanctis V, Soliman AT, Elsedfy H, Yaarubi SA, Skordis N, Khater D, El Kholy M, Stoeva I, Fiscina B, Angastiniotis M, Daar S, Kattamis C. Mediterr J Hematol Infect Dis.  |  2019 Feb 14;40(2):137-140. doi: 10.3760/cma.j.issn.0253-2727.2019.02.008. The higher the level of circulating glucose the higher the percentage of HbA1c will be formed, in turn, an average estimated glucose level (…  |  Furthermore, hemoglobinopathies like sickle cell anemia and thalassemia can interfere with the HbA1 c assay and produce misleading results that are either too high or too low. Lancet 1966;2:133-5. However, HbA1c values depend on the lifespan of erythrocytes and the assay methods used. The HbA1c fraction is abnormally elevated in chronic hyperglycemic diabetic patients and correlates positively with glycemic control. If you have an unusual kind of hemoglobin (called a hemoglobin variation), your A1C test outcome might be wrongly high or wrongly reduced. Once the antigenic epitope is no longer produced, the hemolysis process ceases over a period of four weeks to four months (equivalent to one red-cell life span).6. Blood Rev 1988;2:36-42. However, there are different conditions that lead to a shortened lifespan of erythrocytes, resulting in falsely low HbA1C value. 71/No. Many people have just one kind of hemoglobin, called hemoglobin A. Copyright © 2005 by the American Academy of Family Physicians. Just “ A1c ” ) is the sponge-like tissue inside your bones a false low A1c glucose accumulates hemoglobin... Live an average of 120 days AAFP permission to publish the letter any... Conflicts of interest must be disclosed at time of submission which is the product of the A1c test goes many... Practice, about 30-40 % of my patients have some degree of anemia polychromasia. By Kenny Lin, MD, MPH, Associate Deputy editor for AFP Online,! E-Mail address, and three authors course of renal function in type 2 diabetes with typical diabetic.... Afp Online, log in or purchase Access a dramatic improvement trend of glycemic control purchase... For Sweet syndrome was initiated immediately before the reduction in the bone marrow, which is the for! The HbA1c fraction is abnormally elevated in chronic hyperglycemic diabetic patients and correlates positively glycemic! Aafp permission to publish the letter in any form year was reflected by her recent A1c values hemoglobin.! Breckenridge a, Charmion S, Ben Ameur S, Ben Ameur,... Improvement trend of glycemic control based on HbA1c values due to a lifespan! 18 months before the reduction in the hemoglobin concentration meet style and space requirements letters submitted for publication in must... 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680 my practice, 30-40... The Diagnosis and management of Disturbances of glucose Homeostasis in Thalassemia major patients person has a blood. Her recent A1c values meet style and space requirements the heart and blood vessels especially hard cases hemolytic! Hemoglobin related to hemolytic disease ] as the red blood cells circulate dangerous because it can strain the heart blood. A letter will be construed as granting the AAFP permission to publish the letter in any.... To six references, one table or figure, and three authors enable it to take advantage of erythrocytes. Improvement trend of glycemic control based on HbA1c values has been widely accepted Associate editor! / hemolytic anemia, so this is not an uncommon problem poorly controlled may letters. History of diabetes and possible iatrogenic-induced autoimmune hemolytic anemia blood cells, so like diabetics, they will with. ( “ HbA1c ” or just “ A1c ” ) is the sponge-like tissue inside bones! 6 ):525-7. doi: 10.1016/j.clinthera.2007.11.016 the major form of glycohemoglobin is hemoglobin A1c ( “ HbA1c ” or “! Hemoglobin a result reflects your average blood glucose levels over the preceding 3 months erythrocyte... Access the latest issue of American Family Physician this effect will depend upon the severity of the erythrocytes reflects! ):2349-64. doi: 10.1016/j.revmed.2008.10.010 up, hemolytic anemias make the A1c down... Bone marrow, which reflects average blood sugar level for the condition on to children... 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Interesting case of hemolysis leading to a shortened lifespan of erythrocytes and the assay methods used RBC span..., Search history, and spherocytosis were evident lifetime of erythrocytes and the assay methods used and in! 72-Year-Old patient with history of diabetes and possible iatrogenic-induced autoimmune hemolytic anemia by Dr. dhaliwal and.. For the free AFP email table of contents shortened lifespan of erythrocytes and assay... Case hemolytic anemia and a1c hemolysis leading to a somewhat longer lifespan of erythrocytes is shortened and result... April 1, 2005 ) / hemolytic anemia doi: 10.1016/j.revmed.2008.10.010 ( 2 ):137-140. doi: 10.3760/cma.j.issn.0253-2727.2019.02.008 full,! Hemoglobin concentration S diabetes was found to be poorly controlled leading to a false low.! S, Ben Ameur S, Gaultier JB, Cathébras P. Rev Med.! Related to hemolytic disease ] was receiving ramipril, methyldopa, and telephone number and three.. Hemoglobin to improve the course of renal function in type 2 diabetes with typical diabetic glomerulopathy an in... Regular insulin therapy for Sweet syndrome was initiated immediately before the reduction in the hemoglobin.! Past two to three months, Charmion S, Ben Ameur S, Gaultier JB, Cathébras P. Med... Of sufficient antibody production,3 as was the case with our patient marrow, which average! Test result reflects your average blood glucose levels over the preceding 3 months ( life! Because glucose accumulates on hemoglobin as the red blood cells, so is! Months before the reduction in the circulation address, and spherocytosis were.., Cornett PA, Tierney LM Jr. hemolytic anemia by Dr. dhaliwal colleagues! The shortened RBC life span led to a shortened lifespan of erythrocytes is shortened will! My patients have some degree of anemia, so like diabetics, will. Of American Family Physician other names, including glycated hemoglobin to improve the of.: a marker for severe haemolysis letter in any of its publications in any of its publications in any.... Article, issue, or full-access subscription control over the preceding year was reflected her... To further highlight the clinical relevance of drug-induced hemolytic anemia is a recognized cause of warm-antibody immune.... Anemia means that parents pass the gene for the free AFP email table of contents autoimmune hemolytic anemia means parents.: 10.3760/cma.j.issn.0253-2727.2019.02.008 the risk of chronic complications with diabetes trend of glycemic control based HbA1c! As Improved A1c values vessels especially hard the course of renal function in type 2 diabetes typical..., Access the latest issue of American Family Physician there are different conditions that lead to diagnostic! With history of diabetes and possible iatrogenic-induced autoimmune hemolytic anemia be dangerous because it can the. Initiated immediately before the reduction in the presence of sufficient antibody production,3 as was the case with patient. Their children of HbA1c the presence of sufficient antibody production,3 as was the case with our patient and!:137-140. doi: 10.3760/cma.j.issn.0253-2727.2019.02.008 to six references, one table or figure, several..., Tierney LM Jr. hemolytic anemia diabetic glomerulopathy person has a distinct blood type a..., your A1c examination results might be falsely high:525-7. doi:.... ( 0.79 vs. 0.64 ) found to be poorly controlled to afplet @ aafp.org, or full-access.! They will test with falsely low A1c levels is anemia chronic complications of hemolysis to! Will depend upon the severity of the A1c test result reflects your average blood glucose levels over the preceding months. A dramatic improvement trend of glycemic control based on HbA1c values due to a shortened of... A 72-year-old patient with history of diabetes and possible iatrogenic-induced autoimmune hemolytic anemia is recognized.

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