Aug. 24, 2018
Hazard 3: Distance
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"Houston We Have a Podcast" is the official podcast of the NASA Johnson Space Center, the home of human spaceflight, stationed in Houston, Texas. We bring space right to you! On this podcast, you’ll learn from some of the brightest minds of America’s space agency as they discuss topics in engineering, science, technology and more. You’ll hear firsthand from astronauts what it’s like to launch atop a rocket, live in space and re-enter the Earth’s atmosphere. And you’ll listen in to the more human side of space as our guests tell stories of behind-the-scenes moments never heard before.
For episode 59, Dr. Erik Antonsen, element scientist and emergency physician, discusses the hazard of traveling farther away from Earth an ever before, especially how to provide appropriate medical care with limited resources and challenging communications. This is part three of a five-part series on the hazards of human spaceflight. This episode was recorded on June 28th, 2018.
Exploration to the Moon and Mars will expose astronauts to five known hazards of spaceflight, including distance. To learn more, and find out what NASA’s Human Research Program is doing to protect humans in space, check out the "Hazards of Human Spaceflight" website.
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Gary Jordan (Host): Houston, We Have a Podcast. Welcome to the official podcast of the NASA Johnson Space Center, Episode 59: Distance. This is part three of our five-part series on the hazards of human spaceflight. I'm Gary Jordan, and I'll be your host today. On this podcast we bring in the experts, NASA scientists, engineers, and astronauts all to let you know the coolest information about what's going on right here at NASA. So today we consider another hazard of human spaceflight, the distance from Earth, with Dr. Erik Antonsen. Dr. Antonsen is currently the element scientist for exploration medical capabilities and the assistant director of human systems risk management at the NASA Johnson Space Center. He's also an assistant professor of emergency medicine and space medicine at Baylor College of Medicine in Houston, Texas -- a lot of medicines. And clinically he works as an attending emergency physician at Ben Taub General Hospital. His focus lies on the intersection between medicine and spaceflight. And he's currently tasked with minimizing the risks associated with isolation during exploration-class missions and the inability to provide appropriate medical care.
But first I wanted to start off one last time with Dr. Mike Barratt, who as a NASA astronaut and former flight surgeon gave his own thoughts on the challenges that are presented when traveling far, far away.
Mike Barratt: Well, I think there's many aspects to that. One, I have to kind of think about the medical issues that -- we know our crews are going to be healthy when we launch them, and we're going to do our best to keep them healthy during flight with countermeasures and diet and medical monitoring. But if an acute event happens, somebody, for instance, starts clutching their lower abdomen and peeing out blood, then we think there's a kidney stone, you know, that could definitely happen.
Host: Oh.
Mike Barratt: So in this case, instead of getting a panic call to the ground, asking immediately to talk to the surgeon, what we may get is a report saying, "Crew member so and so was clutching their abdomen in very bad pain. We pulled out the ultrasound, we found a stone. We think it's passing. We've given pain meds, and they're resting comfortably." That's the kind of paradigm that we're moving to so that the crew members, again, are able to respond to an event and handle it the best they can and give us reports and ask for advice, so to speak, consultation rather than real-time guidance. And that, again, is very exploration-oriented. And if we have a whatever settlement or colony or outpost on Mars, that's the paradigm. So that begins with the exploration transit.
Host: Yeah, there's a lot of factors that go into that. Now you're not -- you have to -- you have another base of knowledge that you have to have as a baseline for wherever you go out. Because instead of calling immediately to the ground, like you said, and getting the aid, the knowledge of the experts on the ground instantly, now you have to know sort of what to deal with. And then that mentality of not working together, the mentality of doing it yourself and reporting the progress.
Mike Barratt: Which, truth be told, I think even crew members on station right now -- we understand that we're trying hard to produce science, and having more consultation with the ground is really important. But more crew autonomy is recommended by almost every crew who returns from station, partly to enhance the efficiency and partly for peace of mind. But it is something that crew members really, I think, naturally want and will move into quite nicely. I have to think I had a very small combustion event on the Space Station while I was up there, really almost non-consequential, but that piece of hardware on the Russian segment started billowing smoke and overheating. And, of course, we were able to immediately call to the ground. And they knew about it immediately because of smoke detectors and whatnot. And in this paradigm, it would have been a call back that maybe they would have found out between 8 and 22 minutes later that we had this little combustion event, we pulled circuit breakers, this is what we found. Everything is fine now. We replaced the part that was burning, and we are in normal ops recovery.
How was your day? So, again, that's kind of the paradigm that we'll get to with exploration.
Host: Thanks to Dr. Barratt for providing such great insight over these past few episodes. So with no further delay, let's jump right ahead to our talk about the hazard of distance with Dr. Erik Antonsen. Enjoy.
[ Music ]
Host: Erik, thanks for joining me here today to talk about the distance from Earth.
Erik Antonsen: I appreciate you having me on.
Host: And this is -- this is an interesting topic because it seems so obvious, right? Of course we're going to be far away, but with that comes a series of very challenging things that we're going to have to overcome to be successful. So from a broad perspective, if you were -- if someone were to ask you, "Well, why is distance such a problem?" how would you start?
Erik Antonsen: It has to do with understanding the implications of what distance from Earth means. We have grown up in the space age sort of operating in a relatively close position to Earth for the entirety of our program. And the -- we've had nine missions that have gone outside of low-earth orbit with humans on them. Those nine missions, the last time that happened was in 1972, right?
Host: Yeah.
Erik Antonsen: So there's a question of sort of the corporate memory of how to do that. But there's also a difference in scale and time for the missions that we're talking about. Those missions were like camping trips.
[ Laughter ] We -- we spent most of our time learning the skills that we needed to learn in low-earth orbit where we had some advantages, right? And those advantages from the Human Health and Performance side of the world really can be summed up as three things. One is if something really goes wrong with a crew member, you come back to Earth. You can evacuate them. And that's a reasonably quick timeframe. Another one is that if you need to resupply something -- consumables, medications, food, whatever it is -- that you have a pretty reasonable chance at having a good supply chain for that. And then the last one is beyond evacuation and consumables, the ability to actually talk, right? Real-time communications is something that we rely on in the current operational paradigm, and most people don't realize how much we rely on it. Everything that the crew does is scheduled down to the minute in many cases or at least the five-minute increment. And if they have a challenge with all the myriad of different things that they're asked to be experts in and do on the Space Station right now, they get to reach back, right?
If there's an anomaly, or something wrong, or they can't quite figure out how to get this screw off, they get to reach back through the radio in real time and ask somebody, "Hey, why isn't this working? Can you help me out?" Right? In the context of low-earth orbit, that means that a lot of their -- the information that they have to rely on, the knowledge, the memory, and the ability to process that information is actually displaced from the crew members down to mission control where you have a bunch of people sitting in a room thinking about this, who all have a bunch of people behind them sitting in a room also thinking about this with immediate access to a lot of data that the crew members aren't going to have. Now, take us out of that paradigm, right? Take us someplace far enough away from Earth where you have those three things challenged, you end up in a place where with Mars closest approach, you may have a one-minute -- three minutes one-way delay in communication. And that's just one way, right?
And at its farthest approach you're talking about the speed of light taking 22 and a half minutes one way to get back to Earth. And so that ability, then, to reach back and talk to somebody and say, "Hey, what do I do about this thing that broke here?" You don't have that real-time feedback anymore. Right? And it gets longer and longer and longer the further you go from Earth. When we're around the moon, you still have reasonably close to real-time communications, and we can probably establish a logistics chain to get medicines, food, and other things that we need reasonably well, right? The thing that's really impacted there is if somebody has a medical issue or a problem and they need to be evacuated, you're no longer talking about, you know, a few hours to 36 hours down from low-earth orbit to definitive medical care. Now you're talking about three days, maybe six days, maybe even longer depending on the orbit and the logistics of actually organizing these things.
So all of a sudden, instead of being able to rely on hey, if something bad happens, I can just take this crew member down to Earth and we can deal with it there, now you have to ask the question of how do I figure out in the really limited mass and volume that we have and potentially the limited data telemetry that we have going back and forth between Earth, how do we get enough information and support to our crews so they can make decisions and do just enough to keep somebody alive or stabilize them for that journey that's going to take a much longer time than it did before?
Host: Yeah.
Erik Antonsen: And at Mars, if you don't have that evacuation capability, you're kind of in trouble, right? Because the size of the spacecraft and the amount of stuff that we can bring is only getting smaller.
Host: Right.
Erik Antonsen: Right? That's one of the big challenges. We get less volume to put things in. We get less mass that we get to carry up there. For medical and human performance things, that can mean everything from the food nutrition that you eat to the medicines that you'd like to use, right? All of that sort of stuff, you have less room for it. But maybe even more importantly, the skillsets, right? How do you know when something's a problem? And this is what terrestrial medicine struggles with, right? When you have somebody come to the emergency department, more often than what they're really asking is, "Hey, I've got this thing," either a rash on my skin or a pole sticking out of me or whatever it is, [Laughs] how big of a problem is this, and how dangerous is this, and how fast does it need to be addressed?
Host: The pole's got to be a big one.
Erik Antonsen: I would think so. Some of these are intuitive, but some of them aren't, right? I mean, think about when you go to the doctor, right? Something hurts in my belly, and I don't know what to do about it, right? And it's not going away.
Host: Right.
Erik Antonsen: And so that could be anything from I got some food poisoning from something I ate to my appendix is getting ready to burst, to my pancreas is inflamed, to my gallbladder is a problem, right? That's a huge amount of knowledge that physicians and nurses and other healthcare professionals piece together to try to figure out, all right, am I worried about this or am I not?
Host: Yeah.
Erik Antonsen: And in a setting where you're on the way to Mars, or even around the moon, you know, the decision to actually evacuate somebody or to try to have to intervene on something at the worst can mean loss of human life if we don't plan correctly and at the best might mean screwing up a multibillion-dollar program that we spent a lot of money to put somebody there to do a mission that they no longer can do.
Host: Seems like -- so you're talking about these three things, right? We're talking about these camping trips that -- talking, resupplying. And these elements, it seems like I can just sum them up to autonomy is really what it comes down to, elements and -- of autonomy in all of these procedures and the way that we do things. They're not going to have the help that they have right now on the International Space Station as much.
Erik Antonsen: As much is the keyword there, right? Because it's sort of figuring out what's the appropriate degree of autonomy so that you're not overdesigning a system, you're not trying to do more than you have to do? But you do enough to make sure that the crew that you put in place has the knowledge, the skills, the abilities, all the things and the resources that they need to deal with the things that are most likely to happen or those things that are most likely to be preventable that, you know, we really should be able to deal with beforehand. That's a huge amount of things, right? That's a -- that's everything that could possibly go wrong in the human body is on the list. And how do you start -- how do you start whittling that down? [Laughs] I mean, that's a really big challenge.
Host: Yeah. So if you're talking about a crew going to -- let's just say as part of the crew of a moon habitat -- or let's just say a Mars has been to the in this instance, I'm guessing you would probably want to vouch for a medical person, a medical expert as part of that crew.
Erik Antonsen: So right now in the standards that NASA has, for anything that's considered a planetary mission, we have a requirement to have a physician-level crew member --
Host: There you go.
Erik Antonsen: -- as part of that crew. But outside of planetary, if you're talking about going to the moon, we don't have that requirement, right? And -- and that's -- it's a judgment call, right? Where do you draw that line? It's hard to say.
Host: Yeah.
Erik Antonsen: Right? We have been successfully flying people on the International Space Station for 18 years now, right? And there have been a lot of medical issues that you probably haven't heard about. But there haven't been, like, issues to the level of having to evacuate or having to, you know, consider surgery in-flight or things like that, right? But that's also in a domain where we have things relatively controlled. So if you transpose that back to the Apollo missions, right, to the moon, we actually had a very well-known case with Fred Hayes on Apollo 13 --
Host: Yeah.
Erik Antonsen: -- when he got sick, right? If you went to see the movie Apollo 13, you they that -- that that character, that astronaut got very sick on the way back. And actually, getting a little bit of insight into the story around that is very instructive for how we would think about going back to the moon or how we would think about going further out. See, most people, when they think about the risks that humans face in spaceflight in long duration and outside the Earth's magnetosphere, they focus on things like radiation. They focus on exercise, bone loss, all these sort of things. Sometimes isolation with the behavioral health issues. But it's really hard to quantify what is likely to be the risk from the medical side of things? And so we do probabilistic risk analysis, and we look all the what has happened in spaceflight, we look at what has happened to the astronaut corps on the ground, and we build an evidence base that helps us to try to get our heads around what we think is likely to happen, right? And on Apollo 13, what we saw was a case that's sort of a real-world check for how well we're doing, right?
Host: Yeah.
Erik Antonsen: So interestingly, he had gotten a urinary tract infection, right? These are not very common for men on the ground. And there's an anatomical reason why. They're much more common in women than men because of the length of the urethra that women have, right? But in space, we actually find that that difference fall apart. It changes. We've have had urinary tract infections -- actually a fair amount in men -- up on the Space Station in the MIR program. And the reason why is because of what the spacecraft environment actually does to your body. When you go up in microgravity, all your fluids come up out of your legs, and it turns on your carotid baroreceptors, and it changes the way your kidneys work, and you start peeing out a lot of fluid. And so you get dehydrated, that's one thing. And when they go up, they also end up having some neurovestibular challenges as the signals coming from their eyes get decoupled with the signals coming from their semicircular canals in their ears. So they get space motion sickness or nausea, right? And so they'll take some medicines for that, which are -- Phenergan is one example of them.
Those medicines can actually cause -- one of the side effects that they cause is urinary retention, which can lead to urinary tract infections, right? And so there's a few different factors that contribute to hey, why do these people get urinary tract infections in this domain? And the problem is once they get them, then you have to treat them, right? Crews, when they get retention, will go in and self-cath, which is not a comfortable things to think about. But this is actually part of the reality of being in a different environment like this.
Host: Oh.
Erik Antonsen: And guess what? That also potentially can introduce bacteria into the urinary tract, right?
Host: Huh.
Erik Antonsen: So when Fred Hayes had his problem, part of the reason why he had the problem was because he kept a condom catheter on too long that was supposed to collect urine.
Host: Oh.
Erik Antonsen: Right? A simple thing that could have been avoided. But then what happened is he got sicker. So as urinary tracts progress, most of the time we think of a UTI in terrestrial parlance as something you give a few pieces of antibiotics a couple of days and all of a sudden you're better, right? But in men it's not always that simple. So we try to figure out well, how bad is the infection, right? So for Fred, we had a heart rate monitor, and an increasing heart rate is one signal or one thing that we look at to say are they getting sicker or not getting sicker? And he was getting sicker. We had a thermometer, but it was broken. So we actually couldn't tell if he had a fever or not. We had two different antibiotics that were on the spacecraft at the time, but when we cultured his urine when he got back, we actually found out that those antibiotics wouldn't have worked, that the bug was resistant. It was a Pseudomonas aeruginosa strain that was resistant to the antibiotics. So if we would have tried to treat him with those antibiotics, they wouldn't have helped, right? So what happens, then, is the urinary tract ascends and can get to the kidney and can cause sepsis.
And this is one of those things that is now you've got a very big problem that, if you were able to deal with it in the beginning when it was a small problem and keep it from becoming a big problem, you would have been much better off. So we were lucky with Fred in one sense, even though his spacecraft blew up and he, you know, nearly lost his life because of the problems with Apollo 13. He actually was lucky that he was already being evacuated back home. So once they got home, they were able to treat him with the full armamentarium of resources that they have at any hospital, right, and fix him. Transplant that to a crew that's got three more months left to get to Mars, no ability to evacuate, you can't actually put any new medicines on there if the ones that you have don't work. If you had broken your thermometer, you wouldn't even have insight into how bad he's getting, right? So what we learned from that -- and when we do our modeling sepsis and urinary sepsis is one of those conditions that we worry the most about -- what we learn from that is we need to figure out how to plan medical and Human Health and Performance resources to try to deal with the things that are most likely to happen when they're small problems, not when they're big problems.
Host: So when this happened, you did the analysis and realized that the antibiotics that we had onboard wouldn't have helped anyway. That begs the question well, which ones do you bring on board? How do you know what's going to happen to a crew and what things you're going to have to treat? And that's got to be a huge challenge. Because finite resources is one thing. And like you said, if you want to go home, it's going to be months until you actually can -- if you don't have the antibiotic at hand, it's going to be months.
Erik Antonsen: Yeah, this is a big challenge. And one of the things that we do, it's actually a very unique capability at NASA in the Human Health and Performance Directorate is we merged an engineering technique called probabilistic risk assessment with medical evidence-based medical needs. And so there's a team called the integrated medical model that works on hey, let's take all the instances and all the things that we know that have happened in human spacecraft as much as we can and we'll put that into a database, right? And then we're going to go and look at analog populations, like submariners and people who live in Antarctica, and see what happens with them. And maybe it's not the same thing as spaceflight, but it's a close approximation. Then we're going to go look out at the terrestrial literature and see for the things that we know that have happened in spaceflight or things that have happened to our astronauts on the ground, let's see how often those things happen, right? And you start building up an evidence base that allows you to get an incidence; how often do things occur? Right? And how often do they occur in our domain or in domains that are like that, right? And then you can start actually bring statistical tools to bear to start saying, all right, let's look at what is most likely to happen, let's start looking what the consequences of those things are, what capabilities we would need to deal with those things, what medications we would like to have.
And then you start building up massive databases of this information and process that -- all that data. And you actually run Monte Carlo models to predict well, how many times is this likely to happen based on what we know from the past, right?
Host: Right.
Erik Antonsen: That gets you in the ballpark.
[ Laughter ]
Host: All that for a ballpark.
Erik Antonsen: It's a huge amount of work just to get in a ballpark. But it's an evidence-based ballpark.
Host: Yes.
Erik Antonsen: It's not a single flight surgeon or somebody else sitting there saying, "Well, you know, I saw this one guy who had a urinary tract infection, so we should take this medicine instead of that one," right? And this is the challenge of -- of a growing and learning space program, right? Sixty years ago we were not even necessarily trying to collect a ton of data because we didn't know what was going to be important, what wasn't. It was just the challenge of getting there.
Host: Right, doing it and then figuring it out.
Erik Antonsen: Right? A huge the amount of risk really up in until today has been borne by the launch vehicle, the landing, right, Challenger, Columbia. And a huge amount of risk has not been the failure of the human system within those things, right? But as we go to this greater distance from Earth and longer missions because of that greater distance, that proportion of risk that we carry that is the human system likely to fail gets bigger and bigger and bigger. And the launch and the landing at the beginning and end of that mission makes up a smaller and smaller proportion of the total risk you carry. So part of what we're doing with the ISS and other programs that we work on is to try to build up our understanding of how's that human system likely to fail? What are the things that are most concerning that we need to deal with? And it's not just medicine, right? This is behavioral health. When you put people into isolated chambers as a team for multiple years -- if you remember the Biosphere II project, right, they had eight people for two years stuck in that container, and they ended up all hating each other [Laughs], which is not the team dynamics you really want to have when you're trying to do one of the most challenging things that our species has ever done.
Host: Absolutely.
Erik Antonsen: So a lot of research that we do within this domain is to try to make sure that in the isolation and confinement that happens for this small tin can that we're sending, you know, across the solar system, that we have an understanding of the ways in which people are going to suffer the stress, potential depression, challenges in social dynamics. And this is all behavioral health research that goes on at NASA, trying to inform those. In addition to that, that distance from Earth sort of hazard also crosses a line when we leave the magnetosphere and all of a sudden we have more and more radiation to worry about, right?
Host: Right.
Erik Antonsen: This is the one that everybody thinks of as a giant risk. And it's a big risk, but it's in addition to all these other things that we're talking about. So all the different things that could go wrong start stacking up. And we spend a lot of time and effort trying to figure out, okay, how do we prioritize these things? How do we figure out what are the stuff that we really need to deal with? And how do we design systems so they are intuitive, so they help the crew with more autonomy, so they actually augment the crew? We're not looking to replace the crew with an IBM Watson or something that's like artificial intelligence.
Host: Sure.
Erik Antonsen: I think a lot of times people think that well, we could put Watson on this spacecraft and it might be able to replace the doctor. We don't see that being something realistic anytime in the near future.
Host: Humans are too good?
Erik Antonsen: Humans are too good. And part of the purpose of human spaceflight is for us to explore and to -- and to utilize those skills that humans have. We've already sent robots all over the space -- all over the solar system, right?
Host: Yeah.
Erik Antonsen: This is the next wave. This is what happens when we try to go there and try to figure out how we do things, and how we function, and how we respond to this environment.
Host: That's always the feedback I get. Because that's a question that I love asking all my guests, really, is why do humans have to explore? And it's that -- I mean, you just can't replace the perspective that you get from sending someone to another planet, or destination, or out in the universe in some thing.
Erik Antonsen: I think it's actually more fundamental than that.
Host: Really?
Erik Antonsen: I don't know that it's you can't replace it because you can't right now -- maybe someday in the future you could -- bit it's really that you wouldn't want to.
[ Laughter ] It's a prior assumption, right? We're going there to learn not only about these places but also about ourselves, about our place in the universe, about how we respond and change. And we're learning these things on the Space Station right now. When you talk about the things that happen in astronauts' brains and their eyes and how they're learning to accommodate to long-duration spaceflight what we're really talking about is learning about us in a different environment and what happens, how do we do it? This -- this group of astronauts that exists in this closed container, we've selected them to be really healthy people, right?
Host: Yeah.
Erik Antonsen: So if I'm thinking about clinical research and medicine and I want to ask a question about, you know, what happens if I have this one insult on a healthy person, right, these guys are a control group for an experiment that we as a species are doing, trying to understand how we learn about ourselves. So when we talk about loss of bone, loss of muscle, these are analogs for other diseases and things that can help us inform how we think about those diseases in terrestrial populations in ways that we'd never be able to do on the Earth.
Host: Now, this kind of leads nicely to -- I'm going to kind of combine that with some of the previous statements you made about, you know, we're talking about the supplies and your thoughts about what do we need to collect, what sort -- you know, thinking antibiotics and medicines and supplies? But then also fitting that with a crew that's going to work well together. If you're thinking about going to a destination farther away, now you're talking about, I guess, less and less space -- livable space to do that. You know, we'll have a transit vehicle that's going to go out, and then we're going to have a habitat, but those things -- we're really constrained by the mass that we can bring and the space that's going to be available. And if you're talking, you know, this group of eight people that hate each other after two years, you know, missions to Mars, they can be longer than that. So how do you know -- how do you know what to bring and the masses that you -- based on what you think, this is the medical supplies that we can bring that is going to sustain these people? But then also the people themselves, thinking about those things?
Erik Antonsen: You're really talking about the merger of the science that we do, which is building up an evidence base and an understanding that we can draw from strong conclusions about what's important and what's not, what the size of effects are, and the relative proportion of things that are likely to happen, and the merger with engineering kind of in a systems engineering type of world, right? When you build a spacecraft, right, you have a whole bunch of different subsystems for that spacecraft that you got to accommodate. You have the structures to hold it all together; you have the propulsion system to push it all around; you have the power system to make sure that you can turn the lights on, turn the lights off, do whatever you need to do. Those are all sort of well understood piece parts of a vehicle. And then you also have this human system, right?
Host: Yeah.
Erik Antonsen: Which is the people, yes, but then all the things you need to keep the people alive, like the food, and the consumables, and the things that you're talking about. And then also along with that, the monitoring and the tools that you need to understand the environment that they're living in; is this staying within the parameters we like? The people themselves, are they staying within the parameters that we like? That's where heart rate, and temperature, and some fundamental vital signs, and things like that are really important to know, right? And so it's this gigantic smorgasbord of a lot of information that has to be put together in a systematic approach, right? And that's why this is such a fascinating both scientific and engineering problem, right? We are trying to do something that's never been done before in the history of our species. When I show slides that have, like, the solar system with the sun in the middle and the Earth and then Mars and their relative positions, and I talk about hey, the distance here, the distance that we're going just to get to Mars, one of the things that I say is, "You see that little blue dot that is representing Earth?
At this scale on the solar system, our entire species, everything we've ever known is still within the size of that dot, even the visits to the moon are still within the size of that dot." When I put it up with the Mars orbital distances, right?
Host: Right.
Erik Antonsen: Like, this has to have and has to involve the most rigorous, systematic, and disciplined approaches to both, you know, no kidding understanding what is happening to the human body in this domain and how it changes -- the mind, the behavioral health issues, our response to the radiation environment, galactic cosmic rays, potential solar particle events, our likelihood of medical conditions occurring. You know, the risk that we buy down from selecting the healthiest people in the world has been great for low-earth orbit, but you get diminishing returns when you get out to three years. These people are not superhuman.
Host: Right.
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