No prescription needed

I’m not really an ‘artsy’ kind of person, until a few years ago I never enjoyed looking at paintings or art in particular. I could sort of judge whether the figures depicted looked like they were supposed to be (figurative art), but abstract art? I never saw the point and the idea of enjoying looking at something that might or might not mean something was foreign to me.

My first ‘real’ encounter with art was during a clinic with one of the oncologists at the hospital where I was doing my sub-internship. He had two tiny wooden statues in his window sill and somehow, I couldn’t stop looking at them. They reflected a kind of hope, some humanity in this room full of bad news conversations. I don’t even remember anymore what they looked like, I only remember the emotion of being ‘touched’ by seeing these two pieces of art. I had never experienced that before.

The second time I was stopped in my tracks by a piece of art was in the Louvre. We were in the room where the Mona Lisa was displayed and there was this huge crowd around the Mona Lisa so you could barely get a visual on it. On the wall next to it, there was this painting (The Deposition by dal Ponte/Bassano). At first sight on a computer screen it’s just another of those pictures with a dead Jesus. In real life, the full sized version in the Louvre really draws your attention due to the big contrast between light and dark. I was reminded of acute care settings, of hopelessness – and yet there was this light, hinting at a possibility of a new beginning.

Yesterday, I found another piece of art that really did something. It started with this facebook post:

Without thinking about it too deeply, I proceeded to feel a bit offended. The suggestion that somehow prescriptions for ‘anxious people’ are a bad thing can really set me off.  Patients often tell me ‘I don’t want to change myself with pills’ or ‘I don’t want to rely on a crutch’. So is taking iron tablets or chemotherapy or whatever ‘somatic drug’ a crutch? Medication for anxiety is just as justified as taking iron tablets for anemia.

However, when I calmed down I decided to check out the music and I was very pleasantly surprised. This music was kind, embracing, caring. The soundscape succeeded where the written word failed for me – this track was clearly not meant to criticize medication, it’s meant to provide another option, to show a way to make people feel like someone cares. It’s hope in audible form.

 

 


Seven things no-one tells you about pedal harps

You took the plunge and now it’s there. Your pedal harp. Here are seven useful things to know.

1. It won’t break.
Yes, it cost a lot of money. No, it won’t break when you try to pry the transport cover off (you did buy one, did you?). Nor will it break when you move it. Your new harp is made of nice and sturdy wood, there’s a reason it cost so much! You can just put your hand in one of the sound holes and grab the pillar, just like you would do with your lever harp.

2. Yes, the two lowest strings and the highest string are supposed to lack discs.
Breathe! You didn’t just discover a manufacturing flaw, all pedal harps are made like that.

3. Tuning it may be a challenge 
The first time I tuned my new harp it seemed impossible, I had to stand on a chair to get to the lowest strings and even then it was hard to turn the tuning key on the lowest strings. The lowest C and D are also not picked up by my electronic tuner so it was a bit of a struggle to hear whether it was in tune or not. I found out that it works to play it really softly and then play the string an octave higher and then it’s easier to compare. You can also look at how it vibrates but I am never sure which way it should vibrate. However, after a couple of weeks, you’ll be used to it and tuning 47 strings feels no different than tuning just 34!

4. There’s an art and science to pedalling
Of course you also splurged on heaps of interesting sheet music. So you sit down at your harp and you decide to try that one piece you’ve always wanted to play. You play half a measure… and then there’s an accidental. What to do now? Your feet shuffle a bit and you hear some wonky sounds, but how to proceed?

There are various schools of harp playing, so I can only share what I was taught. You always keep your heel on the floor and then engage the pedal by sort of pushing it diagonally. In the beginning it may help to first slide it out of its slot and then pressing it down/letting it go but that doesn’t work anymore for fast pedal motions. So you are not really pushing on the pedals like driving a car (or like I imagine how you’d drive a car :) ) but you sort of lightly touch them on their lateral side. It helps a lot to wear heels if you are not too tall.

Then, when you can comfortable move the pedals into various positions, it’s time to try to combine playing with pedalling. In the beginning everything will fall apart because you have to concentrate on two things at once, but supposedly, eventually you will be able to continue playing without stopping or producing weird pedal-related noises.

Do not give up! It takes a lot of practice! Try to refrain from the temptation of looking at your feet. Try playing in your socks. It will really get better, don’t feel like you fail at being a good harpist if you can’t do it in one week.

5. Writing in the pedal markings before you start playing saves you a lot of annoyance
Some music already contains pre-written pedal markings but in most cases you’ll have to figure it out yourself. I was sorta used to writing in lever changes, but it was a bit daunting to start on the pedal changes, especially as I wasn’t any good at it. However, pedal changes work almost the same as lever changes. Sit down with your score, see where the accidentals are and write in where you could feasibly do a pedal change. Easy, right?

But how do you decide where it’s feasible? First you look at where the pedal is needed again. Even though you will probably struggle with the pedals a lot in the beginning it works to put in the pedal marks as if you could properly do them. So don’t engage a pedal 4 measures before you need it, I generally write them on the beat. Don’t forget that all the notes change pitch when moving a specific pedal, so you should also pay attention to when you last used it. It takes a while before you get the hang of the pedals but that’s totally normal!

6.  Playing it is like a full body workout

If you were previously a bit lax about posture, the pedal harp will punish you for it by making you feel sore as though you ran 10 miles yesterday. So don’t forget the low shoulders, sitting straight on your ischiadic spines, keeping yout head in a neutral position etc. etc. Something new may be the balance point, where lever harps are rather light, you can’t carry the full weight of a pedal harp on your right shoulder without getting injured after a while. So try to find a position where it will rest very lightly on your inner knees and a litle bit on your shoulder – there should be one (the balance point of the harp). It may also be necessary to adjust the height of your bench and the distance to the harp.

And take it easy, it’s probably better to restrict the playing to 30 mins at a time during the first few weeks (which is almost impossible, I know!).

 

7. Buy a harp trolley as soon as possible – don’t wait until you’ve finally scheduled your first concert.
These things are way over priced but not being able to move your harp outside the house apart from lifting it and carrying it is extremely annoying. Order it now! I didn’t and I had to stress until it was delivered a couple of days before Christmas.


Oops.

Some of you may be familiar with the stereotypes of medical specialties (nicely illustrated by Michelle Au over here). Surgeons are mostly loud people who love ‘doing things’, internal medicine docs will agonize over 0.01 change in obscure lab values, psychiatrists are hippy softies etc.

While part of this is making fun of ‘the others’, knowing a bit about each specialty helps you to properly frame requests and also to know what someone will or won’t do. ‘He’s a typical surgeon’ tells you that he won’t hesitate to act but doesn’t enjoy lengthy thinking about labs and differentials. Surgery is not going to manage someones insulin so you should make a plan for them and not expect them to learn how to do it themselves. ‘Maybe we should hold off on the internistic thinking for a while – what do we actually know about this patient’s social situation?’ would also be a valid contribution to grand rounds. The day to day use of these descriptives is so ingrained in my daily practice that I sometimes forget that the lay public has a very different perception of all of this.

‘I’m most definitely not a surgeon,’ I told the people who were going to host me during my final rotation. ‘Not my kind of people,’ – it’s true, I’m introverted, less brash. This got us off on the wrong foot from the start: their neighbor had just retired as a surgeon in the local hospital and they knew him as a kind man who would often cycle back to work after dinner to visit next day’s surgery patients. I know that that was either poor planning – patients are usually admitted in the afternoon and it’s not very nice to let them wait for hours – or he would just return to the hospital because he was on call. But in their perception, all surgeons were awesome people, so me saying something akin to ‘I don’t like surgeons’ was very offensive for them.

In another instance, I was discussing a case of unexplained illness and I remarked ‘of course, it was a typical internist -‘ and then I was fully reamed out, as that person had a relative who was an internist and they love piecing the puzzle together, searching for a diagnosis – how could I say that about internists because I know they will not give up- well, sorry, yes, they will. If all the labs and tests are normal, a typical internist will insist everything is fine and if you are still feeling ill, maybe a psychologist is a good idea. There are very few doctors who take ‘unexplained symptoms’ as a challenge and feel personally responsible to manage their care. Consult to psychiatry with no follow-up is the common solution, unfortunately.

I work in a patient population which spends years looking for a diagnosis (‘tiredness ”upset stomach’ ‘weird skin rashes’) and then suddenly gets diagnosed with a terminal illness when all the pieces are finally there. So this kind of hit close to home – reality is often far from the ideal world in which all doctors continue to feel responsible to their ‘difficult’ patients. We keep letting patients slip trough the cracks of the system because we don’t understand whats wrong with them. But that only reflects our ignorance!
These two interactions really opened my eyes to be a bit more careful regarding the stereotyping when speaking with lay people – some things just can’t be explained in a short conversation. In both instances I didn’t feel comfortable to try to convey my viewpoint because of the vehement reaction. I know what surgeons and internists are like, I’ve done four months worth of rotations in each plus a half year sub internship – and I want to become an internist myself (but with a special focus on unexplained complaints). I certainly don’t ‘hate’ surgeons  – now I’m not a clerkship student anymore I actually rather like interacting with them. But I’d be lying if I said that I was a typical surgeon (on my evaluation, the head of department wrote ‘not a typical surgeon, good luck in internal medicine’ – end of discussion :) ).


So you want to buy a pedal harp

You’re not a 6-year old prodigy, you’re an adult buying your first pedal harp from your hard-earned generously gifted money. You love your harp teacher and will certainly bring them along but in the end, you would like to make your own decision. There is surprisingly little information about how to buy a pedal harp. So here are my tips! (Evidence class E or so, non-expert opinion based on N=1 and I happened to be the test subject. So do take this with a grain of salt :) ).

The goods

It helps a lot to know what’s out there. There is an entire range of pedal harps, from the concert-hall grade concert grands to harps geared toward students/ and others on a budget. Of course I dreamed of a L&H Style 23, but that would have required taking out a mortgage so that wasn’t an option. There are plenty of harps for people who can’t afford the Ultra Top Of The Line Models but would still like a good instrument that could possible be of use in an orchestra / public recitals. Actually, apparently there are heaps of people, even professionals, playing their straight-backed Daphne in orchestras. Or so my harp teacher told me.

So, for me, the options were the Salvi Daphne series, the Salvi Arion, the Camac Clio and the Lyon and Healy Chicago. ‘Stretch goals’ included the Salvi Aurora and the Lyon and Healy style 30. I know that Pilgrim offers very affordable pedal harps but I’ve never liked their sound  so I haven’t tried them. You can visit the websites of various harp makers to see what they are currently offering. (I didn’t mention Aoyama and Venus and there are probably many more harp builders).

Let’s not forget the option of buying second hand! This may allow you to acquire a harp from a higher price segment, but the downside could be that the harp is nearing the end of its life cycle. Harps that were intensively used by a music school or an orchestra may sound like a nice deal but can end up costing lots of money in repairs and regulation. Eventually, I decided not to go down this road because I have been playing a clunky old harp for years – I allowed myself the ‘present’ of not having to worry about things falling apart or soundboards imploding.

Harps being sold by professionals or students upgrading to a newer / other model remain a good option – usually these harps are very well cared for and in a good condition, but then you need to be lucky that someone is selling their harp at exactly the moment you are looking for a new one. I can imagine that this option (waiting and seeing until you find a nice ‘deal’) is a good option for younger students or if you are very happy with your current harp. Check the listings of local harp societies and craigslist-type websites to see what’s available. In the Netherlands, there is folkharp.nl and nederlandseharpvereniging.nl and marktplaats of course. There are a lot of nice used pedal harps on marktplaats!

Preparation

The integral part of harp shopping is that you’ll need to try various harps and listen/feel to what happens when you play it. So it really helps to be prepared to play a lot of harps! I wish I’d practiced more before I went – now I blacked out in the middle of the Handel concerto. I did bring some sheet music, though, that saved my a** in the end. Definitely don’t be afraid to play other genres on it for testing if that’s what works for you!. In the end, I mainly used the Montfort Bourree for sound testing because I knew exactly how it was supposed to sound like.

Another consideration is that it helps to know how to move pedals. I couldn’t play anything with pedals when I went pedal harp shopping, but I at least knew how to put them in various keys. I didn’t practice for this but I’ve played on a pedal harp during my lessons so that really helped.

The Harp Shopping Itself

If you’re shopping for a new harp, or just interested in trying lots of hatps, visiting a harp store is the next step! Try to find out whether you need to make an appointment beforehand – though judging the response when you show up unannounced can also give you an indication whether you would like to spend a year’s salary on this shop/these people. Sometimes there will be harp exhibits – then a harp builder ships lots of harps to the shop and will display them there for a week or so  – don’t expect loads of harps and loads of types to be in stock if there’s not an exhibition.

Be sure to try various brands – be sure that you tried at least 1 Camac, 1 Salvi and 1 Lyon and Healy harp. You will hear the differences even when not really musically trained (like me), even your ‘layman’ partner will hear it. Stick with the brand you like and don’t let yourself be led astray by the ‘image’ or ‘branding’ of a certain brand. Actually, I thought I’d prefer Camac because I had heard that Salvi harps were really tight and heavy to play.

List of things to check

When not playing 

How does it feel on your shoulder? Heavy? Light? Can you find the balance point?

Can you reach all the strings without having to contort yourself / bumping into the soundboard?

How are the pedals? Easy to move? Hard to move? This heavily depends on your pedal harp skill so I didn’t judge my harp by this criterion. Now I’m still happy with my choice, I think my harp pedals lightly but not too light.

When playing

Try the different registers. Apparently, the sound will change and ‘mature’ when you play the harp more, but of course you have to like what you hear. The lower register will usually mellow a bit more and the higher registers will display less change – apparently (this is all what people said to me while I was trying the harps, so I can’t judge the evidence-based ness :) ). Also, check if they strung the highest registers with nylon because then the highest registers can sound a bit off – restringing with gut as soon as you’ve bought it is the best option then.

Feel how each register plays. Is it tight? Or not at all?

Try the harp in various pedal settings, is the sound still nice and resonant with all the pedals engaged?

How to ‘try’ the harp? Well, play some scales, some chords, try playing pieces in the different registers. Here’s where that preparation comes in. Definitely don’t forget to check your posture.  If you’re not very tall, you might see that the large concert harps aren’t really feasible. Personally, I chose for the most ergonomic nice sounding harp. Why make learning more difficult?

For me it was really hard to judge all these things when playing on just one harp – it helped to switch back and forth and directly compare things.

When listening to someone else

Have someone else play your harp! Bach on your harp? Jazz? Some classical sonata? While I was pretty advanced lever harp wise, I didn’t really know any pieces which utilize pedals or pieces in other tonalities than on the lever harp. It was great to have my two top choices played by a professional who could really make it sing!

Listen how it projects and do you like what you hear? There are probably more technical things to listen for, but I listened mostly ‘with my gut’ (emotion).

 

Making a decision

This was of course the hardest part, spending so much money and hoping that this will be THE instrument, the one you’ll probably be playing for life. You’ll know when its the one. It’s just like shopping for a wedding dress! It’s mostly emotion.

Don’t be afraid to call it a day and come back later, yet you’ll probably not get a note from heaven telling you that this is going to be the harp. Just like picking what you’re going to study in uni, you probably can’t be a 100% sure.

Trust me, all doubts will be gone when your pedal harp is finally delivered at your home and you have this huge instrument sitting in your living room… :)


Dancing through the plateau

“I don’t know, I’d rather focus on just dancing than spending much time thinking about the mechanics of a move”

“Why do I have to pay so much attention to connection? I can’t relax anymore now!”

“I don’t care about how it looks when I step, it feels right and then it’s okay!”

“There is so much to think about, rhythm, musicality, connection, now I can’t concentrate on having fun anymore!”

The statements above would sound really stupid to most dancers. Posture, connection, paying attention to what your body does is the core of a nice dance, it’s what makes it fun and enjoyable, not the other way around. The heightened body awareness brought on by lots of lessons and practice allows you to have fun and you will eventually internalize a lot of it so you won’t have to spend every minute thinking about it and can instead concentrate on the music and the dance itself you’re creating with your partner. But before you reach that level, there’s lots of stepping on toes, stiff muscles (due to not knowing how to hold proper posture), confusion about how to ‘feel’ something in your body, etc. etc. Crossing over to another style of dancing may feel like you’re dancing blindfolded and with gloves on until you get acquainted with the mechanics of another type of frame.

And yet… when playing the harp I apparently have a lot of these preconceptions. My journey in learning to play the pedal harp has led me to another teacher and her lessons are completely different from what I was used to. In a way, it’s like learning to play harp all over again.

First of all, it is about critical listening. What kind of tone am I producing and is it what I want? Am I hearing what I’m doing or am I hearing what I’d like to hear? I never paid much attention to how equal all the notes in a scale are, but apparently, it was very uneven. Are the notes in a chord completely simultaneous or are some of them off? And not just focus on these aspects as a one-time event, but ask yourself these questions over and over again in every piece.

Then dynamics. What do you want to convey and how? I notice that I still have a huge gap in knowledge and listening ability. Because I used to think that dynamics are sort of childish, I really thought that being able to play a piece well was playing the notes well and evenly, and not make it too dramatic. My previous teachers certainly cannot be blamed for this, I don’t know how I got this preconception, but it’s there and I really need to work on learning to control dynamics, to listen for them in my own playing and to develop a kind of idea on how to use dynamics in a piece. My current teacher is very strict with this and won’t allow me to accidentally forget about the dynamics aspect. She will work with me and try to find examples until I understand ‘how to do it’ and ‘how to control it’. It won’t work to just tell me about a musical shape or an effect, but it really helps to break things down and create exercises to isolately practice dynamics. And it just needs a lot of specific practice. I found myself saying ‘well, I can easily play the notes, but then the dynamics…’ but that’s essentially still saying that I can’t play it, just the notes is just half of the story. It’s like saying, I know the steps but I can’t follow.

As my teacher also gives very specific tips about how to practice things, my practice sessions are now transformed from trying to play through a piece and focusing on making it work technically to working on a long list of specific things. On one hand it is nice to know, it’s clear what to do and what needs to be improved. On the other hand, it is a long list and it is really hard to think of everything at once. I used to mindlessly play my pieces, enjoying just the sounds and the harmonies, practising to ‘get it in my fingers’. But actually I wasn’t listening at all. Now it takes a lot of concentration and harp playing isn’t my mindless outlet anymore, it’s actually a lot of work and takes a lot of brain power!

Something new is also how to start playing. I just started out of the blue. But actually, that isn’t natural at all, in dancing you would also first make a connection with your partner and then do the first step. It felt a bit stupid when I did it for the first few times, but sitting behind the harp, then pulling it toward you, putting your feet on the pedals, deliberately touching the strings, inhaling and then playing really makes a difference. Even though I still tend to forget, so far my teacher has had to remind me to BREATHE before I start every lesson.

I try to tell myself that it will probably get better, just as in dancing. Maybe I’ll once be able to do a lot of the things I’m now struggling with without thinking. But for now, almost every lesson is a complete turnaround of how I have always viewed harp playing – maybe it’s a bit stupid in hindsight, but I’m glad to be learning now!

I was sort of in a plateau, mainly caused by the fact that I apparently never developed the ability of being able to critically listen to myself (apart from right/wrong notes and tempo). My harp lessons the past year felt like they were not really progressing, I was learning new pieces but I didn’t feel like I really improved my playing. Now I’ve broken through that plateau with the help of my teacher. In a way this is exhilarating, there is so much to discover and to learn! It also reminds me that I have a long way to go- I really hope I can transform my struggles into a fluent ‘dance’ on the harp.

 

 


A new member of the household

Every time I enter my living room, I’m pleasantly surprised by the sight of this new member of the household. He’s large, dark brown and very beautiful: my new pedal harp.

Due to extremely lucky and amazing circumstances I was able to buy a pedal harp. Apparently, my parents and grandparents were secretly saving up for me. I remember how I often whined to my parents that I’d like to have a better harp than the clunky old thing I have – now I feel slightly ashamed, knowing that they were working on it. I think I prefer it this way, not knowing that they were planning to buy me a harp and now being extremely pleasantly surprised by it.

It is a dream come true, a lot sooner than I expected. I was just coming to terms with the fact that things like getting my diver’s license, buying a car, finally buying some decent furniture have a higher priority than ‘saving up for a harp that costs four times as much as the car we’re looking at’. My harp teacher gave me really awesome pieces that are very challenging so I had myself almost convinced that I wasn’t ready for it anyway.

And then the pedal harp happened. I’ve always been a huge lever harp proponent – no the lever harp isn’t a starter harp, you can have fun with it for life!!! – but this instrument, well it’s something completely different. The pedals are one thing, but the size and increased string tension is another factor: I actually got muscle aches all over after having it just one day, it takes a lot more core strength to play it. They’re both called ‘harp’, but playing on this huge guy is more like tango dancing than blues dancing, it really demands a lot in terms of technique and posture. And I love it. It’s like starting a new style of dancing, getting to know your body in a different way, finding faults you hadn’t noticed before and discovering something completely new and amazing you didn’t know that existed. The sound; when I pull the bass strings it sings and resonates through the entire house!

My harp teacher forbade me to practice more than 1 hour a day and told me to practice in 3 blocks of 20 minutes to avoid overstraining my muscles. Just one hour is really short and after 20 minutes I am just getting into it! I can totally imagine why some patients ignore their doctor’s advice… :) Of course I tried to play all the pieces I’ve always wanted to play (these pedals take some time getting used to!) and every now and then I’ll remember another cool piece and add it to my ‘finally able to start studying this!!!’ list.

So the lever pieces are now on hold (Clair the Lune, I will get back to you!!!) and I’m working on some pieces to get used to the pedals: the Serenade Melancholique by A. Hasselmans, the first prelude in the first prelude book by Bernard Andres and the sonata in C minor by Sophia Dussek. Yes, the sonata in C minor with the awesome bass part. My struggles with the sonatina in G major did pay off because I can manage this piece, it is most definitely less difficult than Clair the Lune. Apart from the pedals it only consists patterns I’m familiar with, it’s a lot like a cross between the Händel concerto and the Sonatina in G. It is sooo nice to finally play this!!!

Here’s the first line in practice tempo, of course it doesn’t sound like how the professionals play it. But just to produce these lines of music myself… It really is a dream come true.


A most precious gift

Clinical research would be impossible without patients who generously donate their blood and other tissues. We use their samples to validate data gathered in animal or cell-based studies – a certain treatment may work wonders in mice but if it doesn’t work on human cells it’s probably not worth it to investigate the compound in clinical trials. Donated samples are also essential to gain knowledge regarding fundamental processes in the body and how disease affects them.

On a daily basis I ask patients if they are willing to participate in research. It’s a short conversation in which I briefly explain the goal of the study, what participation entails and the pros/cons of participation. In the case of a blood donation it usually means donating a few extra tubes (10-20 mL), scheduled to coincide with their regular blood draws so there is almost no discomfort involved (no extra needle stick). However, sometimes participating involves taking a skin biopsy. This is a more invasive procedure with more discomfort and you’ll have a small but visible scar afterwards.

So naturally not everyone wants to participate. And that’s okay, because it’s still your body and your decision. I am very happy with the samples I can obtain, they’re irreplaceable gifts to the field of medicine – but it’s not like my day is ruined just because someone said no. That’s sort of the reason for informed consent – you always have the option of declining and no one will hate you for it.

For some patients, this is hard to understand, they tell me how bad they feel that they don’t feel like ‘giving something back’ or they are worried that it will impact my research projects. This really touches me, because why would they feel bad? I’m the one asking an outrageous question – would you be willing to receive a scar so I can look at your cells in the lab?

Apparently, not all scientists have this mindset because the rules regarding clinical research are very strict (for instance, the reason that there are physician-researchers who are not directly involved in patient care is that the doctor-patient relationship isn’t tainted by a request to participate in a study). You are not allowed to make the patient feel pressured in any way, so if someone declines you can’t really persuade them to participate anyway, apart from providing factual information regarding questions they have.

When a patient expresses that they feel bad about their decision to say no, I try to take some time to reassure them that it really doesn’t matter. I wonder whether they really understand, though. So hence the blogpost – I value it that people are willing to talk to me and consider participating, I see it as my job to help people reach the decision they want, I’m not afraid of checking if they are completely sure if I notice that they seem a bit unsure. I’d rather exclude someone than include a person who didn’t participate of their own volition. And, in the end, I’m doing this research to benefit patients. The end doesn’t justify the means, if I don’t do justice to their right to refuse, how can I still say I’m all doing this for the patients?

Sometimes, this short informed consent conversation develops into a longer interactions where patients tell me about their journey in medicine so far and how interesting is is that someone finally respects their decision. Interactions like these reinforce my idea of how I’d like to practice medicine. Patients should always be given a voice when it comes to important treatment decisions. And not just ‘do you consent to this operation’, but listing all the options, the pros and the cons and the alternatives. Because that’s what we do in clinical research, so why not in clinical practice?


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