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Muhtarul Anam
It's all about my life
Rabu, 08 Juli 2015
Senin, 15 September 2014
jurnal muskuloskeletal
Clin Geriatr Med. Author manuscript;
available in PMC Aug 1, 2011.
Published in final edited form as:
PMCID: PMC2920876
NIHMSID: NIHMS193463
Age-Related Changes in the
Musculoskeletal System and the Development of Osteoarthritis
The publisher's final edited version
of this article is available at Clin Geriatr Med
Abstract
Synopsis
Osteoarthritis (OA) is the most common cause of chronic
disability in older adults. Although classically considered a “wear and tear”
degenerative condition of articular joints, recent studies have demonstrated an
inflammatory component to OA that includes increased activity of a number of
cytokines and chemokines in joint tissues which drive production of matrix
degrading enzymes. Rather than directly causing OA, aging changes in the
musculoskeletal system contribute to the development of OA by making the joint
more susceptible to the effects of other OA risk factors that include abnormal
biomechanics, joint injury, genetics, and obesity. Age-related sarcopenia and
increased bone turnover may also contribute to the development of OA.
Understanding the basic mechanisms by which aging affects joint tissues should
provide new targets for slowing or preventing the development of OA.
Keywords: aging, osteoarthritis, articular cartilage, elderly, cell
senescence, oxidative stress
Introduction
The
prevalence of osteoarthritis (OA) increases with age such that 30 to 50% of
adults over the age of 65 years suffer from this condition1,
2.
Radiographic changes of OA, in particular the presence of osteophytes, are even
more common such that radiographic surveys of multiple joints (hands, spine,
hips and knees) reveal OA in at least one joint in over 80% of older adults3.
However, only about half of people with radiographic OA experience significant
symptoms. Likewise, not all older adults with symptoms of joint pain have
radiographic evidence OA in the painful joint. In a study of 480 adults over
the age of 65 years who reported chronic knee pain, only about 50% had
radiographic evidence of knee OA4.
Although
OA is most common in the hands, involvement of the knees and hips is usually
much more disabling. Radiographic involvement of the distal interphalangeal
joints in the hand was present in more than half of men over the age of 65 and
more than half of women over the age of 55years5
but only thirteen percent of men and 26% of women over the age of 70 were found
to have symptomatic hand OA6.
The prevalence of radiographic knee osteoarthritis in subjects aged 60 and
higher increased with each decade of life from 33% among those aged 60-70 to
43.7% among those over 80 years of age while the prevalence of symptomatic knee
OA in these subjects was 9.5% and increased with age in women but not men7.
In the Johnson Country Osteoarthritis cohort, the prevalence of radiographic
knee OA rose from 26.2% in the 55-64 year range to nearly half of participants
in the 75+ group and the prevalence of symptomatic knee OA likewise increased
from 16.3% to 32.8% between these age groups8.
Symptomatic hip OA in this cohort was reported as 5.9% in the 45-54 age group
increasing to 17% in the 75+ age group9.
The
relationship between aging and OA is well known but the mechanisms for how
aging predisposes the joint to developing OA are still not fully understood.
Changes both intrinsic to the joint as well as those extrinsic (such as
sarcopenia, altered bone remodeling and reduced proprioception) contribute to
the development of OA. The concept that aging contributes to, but does not
directly cause OA, is consistent with the multifactorial nature of this
condition and the disparity in which joints are most commonly affected. In this
chapter, current concepts of the biology of OA will be reviewed and the
relationship between aging and the development of OA will be considered.
The Pathobiology of Osteoarthritis
OA
is a multifactorial condition but the pathological changes seen in
osteoarthritic joints have common features no matter what the cause(s) of the
condition in a given individual. These features include degradation of the
articular cartilage starting at the joint surface and progressing to full
thickness loss, thickening of the subchondral bone with accumulation of poorly
mineralized matrix, osteophyte formation at the margins of joint surfaces,
variable degrees of synovial inflammation with limited pannus formation,
degeneration of ligaments and, in the knee the menisci, with eventual
ligamentous rupture and meniscal extrusion, and hypertrophy of the joint
capsule contributing to joint enlargement (Figure 1). In some individuals, increased subchondral bone
remodeling results in bone marrow lesions detected on MRI and, in many older
adults, calcification in the articular cartilage and/or the menisci is seen on
plain radiographs. In the articular cartilage, the earliest changes at the
joint surface occur in the areas that receive the greatest mechanical forces.
As OA progresses, the loss of the articular cartilage affects joint movement
due to the loss of a smooth lubricated surface responsible for the normal
gliding motion of the joint. The pathological changes noted in the other joint
tissues also contribute to the loss of normal joint function and, because
unlike the cartilage they contain pain fibers, these tissues are responsible
for the pain experienced by people with OA.
Pathology of osteoarthritis
There
are reasons to believe that although OA has common pathological features seen
once the disease becomes advanced, it may start with selected features that are
dependent on the initiating factors in a given individual. For example, in an
individual with post-traumatic OA resulting from rupture of the anterior
cruciate ligament the condition likely started with a period of acute joint
inflammation with synovitis and cartilage matrix destruction followed later by
development of bony changes while in an individual with OA related to obesity
it may have started with increased bone formation followed by articular
cartilage matrix destruction and secondary synovial inflammation stimulated by
release of cartilage matrix fragments. The early stages of OA have been
difficult to study. Most people do not develop symptoms until significant joint
damage has occurred, commonly after age 50-60 years, but there is radiographic
evidence for OA in a significant percent of women beginning in the early 40's10.
Researchers are attempting to develop biomarkers and advanced imaging
techniques that could detect early stage disease but given the slowly
progressive nature of OA it will be some time before sufficient information is
available to determine the predictive power of these techniques.
At
the cell and tissue level, cartilage in OA is characterized by an imbalance in
matrix synthesis and matrix degradation. The chondrocyte is the only cell type present
in articular cartilage and therefore is responsible for both the synthesis and
the breakdown of the cartilaginous extracellular matrix11.
Signals generated by cytokines, growth factors, and the matrix regulate
chondrocyte metabolic activity. In the early stages of OA, there is evidence of
increased matrix synthesis, although not all the matrix proteins produced are
the same as those made by normal adult articular chondrocytes. There is
increased expression of the fetal form of type II collagen (type IIA)12
and of type III collagen and fibronectin13,
14
as well as proteoglycans with altered sulfation patterns15.
Progressively, excessive matrix degradation overwhelms matrix synthesis and
this appears to be due to inflammatory and catabolic signals that are present
in excess of the anti-inflammatory and anabolic signals (Figure 2). Pro-inflammatory cytokines found in OA cartilage include
IL-1, IL-6, IL-7, IL-8, and TNF-α to name just a few. The presence of a large
number of inflammatory mediators within the articular cartilage indicates that
OA is much more inflammatory than previously thought. The excess of
inflammatory signals inhibits matrix synthesis and promotes increased
production of matrix degrading enzymes, including matrix metalloproteinases
(MMPs), aggrecanases, and other proteases that degrade the cartilage matrix. As
OA develops, chondrocytes can assume a hypertrophic phenotype characterized by
production of type X collagen, alkaline phosphatase, and matrix
metalloproteinase (MMP)-13 (collagenase-3)13.
Catabolic and anabolic factors that
regulate chondrocyte function
Chondrocyte
death has been observed during the development of OA but whether this is an
early or late event is not clear16,
17.
Because cartilage lacks an abundant supply of stem or progenitor cells, the
loss of chondrocytes to cell death results in a decline in cell numbers. This
is most apparent in the superficial region of the articular cartilage. Although
normally adult articular chondrocytes rarely divide, there is evidence for cell
proliferation during the development of OA resulting in clusters of
chondrocytes being present. However, these cells are unable to maintain the
matrix which may be due at least in part to a reduced ability to respond to
growth factor stimulation further contributing to an imbalance in matrix
synthesis and degradation.
In
contrast to matrix loss in the articular cartilage, the subchondral bone
undergoes increased matrix production resulting in a thickening of this region.
Older theories of OA suggested that the increased subchondral bone resulted in
increased stiffness that contributed to the degradation of the overlying
cartilage by increasing local stresses18,
19.
However, later studies found that the subchondral bone in OA was poorly
mineralized and perhaps less stiff than normal bone18-20.
More recently, studies have focused on inflammatory mediators produced by
subchondral bone cells that could diffuse through the calcified cartilage zone
or enter through cracks in the calcified cartilage and negatively affect the
overlying articular cartilage21.
The presence of localized areas of increased bone remodeling detected by bone
scans or by MRI has been noted in areas of cartilage loss and is associated
with pain in OA22.
The correlation of these lesions in the knee with the location of excessive
loading, i.e., medial bone lesions in association with varus alignment and
lateral lesions with valgus alignment, suggest they are mechanically mediated23.
The
degree of synovitis present in OA is variable. In people with OA severe enough
to require knee replacement, about a third of patients had marked synovitis,
one third moderate synovitis, and one third little to no synovitis24.
This suggests that synovitis may be important in a subset of people with OA but
it is not required to progress to end-stage disease. However, an arthroscopic
study of people with early OA did find an association between the presence of
synovitis and progression of cartilage lesions measured a year later25.
Studies of OA synovial fluid have revealed the presence of inflammatory
cytokines that could be involved in stimulating cartilage destruction as well
as destruction of other joint tissues such as the meniscus and ligaments. The
growth factor TGF-β, although an important contributor to cartilage matrix
production, may be responsible for the stimulation of synovial hypertrophy as
well as osteophyte formation26.
Although
the synovium is involved in OA, the extent of inflammation is usually less than
that found in rheumatoid arthritis (RA) where pannus formation is much more
extensive and appears to be directly responsible for joint tissue destruction.
The extent of synovial inflammation as well as higher systemic levels of inflammatory
mediators has been used to classify RA as inflammatory arthritis and OA as
“non-inflammatory”. However, as noted above, inflammatory mediators are
responsible for joint tissue destruction in OA and elevated serum levels of CRP27
and cytokines including IL-628
in people with OA indicate that inflammation plays a role in OA as well as RA.
Risk Factors for Development of OA in the Elderly
Besides
age, the common risk factors for OA include obesity, previous joint injury,
genetics, and anatomical factors including joint shape and alignment29.
Additional factors include gender, race, and nutritional factors, such as
vitamin D deficiency30,
31.
These risk factors appear to interact with age to determine which joints are
affected by OA and how severe the condition will be (Figure 3). A joint injury earlier in life predisposes that
particular joint to OA later in life32.
There is also evidence to suggest that an older adult will develop OA faster
than a younger adult after an acute joint injury such as an anterior cruciate
ligament tear33.
Other age-related factors that contribute to the development of OA include a
decline in muscle strength, loss of proprioception, degenerative changes in the
meniscus and joint ligaments, increased bone turnover, as well as calcification
of joint tissues29,
34,
35.
Relationship between osteoarthritis
risk factors and aging changes that interact to promote the development of
osteoarthritis
In
terms of knee OA, recent MRI studies have revealed the important role of the
meniscus. Incidental meniscal damage on MRI is quite common in the elderly,
ranging from a prevalence of 19% in women aged 50-59 to 56% in men in the 70-90
year-old age group36.
The prevalence increased to 63% in symptomatic subjects with at least moderate
radiographic OA measured by plain films. In a longitudinal study, symptomatic subjects
with significant meniscal damage had an odds ratio of 7.4 for the development
of radiographic knee OA37.
These studies suggest that age-related changes in the meniscus may contribute
to meniscal degeneration that in turn may contribute to the development and
progression of knee OA.
Recent
MRI studies have also shown that anterior cruciate ligament (ACL) disruption is
common in older adults with knee OA, even without a known history of trauma38.
A well known risk factor for the development of post-traumatic knee OA,
age-related changes in the ACL may predispose the ligament to spontaneous
rupture or rupture after minimal trauma. Changes which occur in aging ligaments
such as increased stiffness from collagen crosslinking combined with decreasing
fibril diameter may increase the risk for ACL tears39.
Studies are needed to better characterize aging changes in joint ligaments and
determine if the mechanisms are similar to those occurring in other
soft-tissues in the joint such as the cartilage and meniscus.
As
detailed above, the subchondral bone is clearly involved in the development of
OA and knowledge is being gained on the mechanisms which seem related to
increased bone remodeling and the laying down of an abnormal matrix, processes
that are potentially affected by aging19,
40.
Bone marrow lesions detected by MRI in people with OA are associated with pain
and with disease progression22,
23,
41.
First thought to represent edema because of their bright appearance on
T2-weighted MRI, these areas most likely represent areas of localized
remodeling42.
The association of bone marrow lesions with malalignment suggests excessive
loading may play a role in their development. Increasing age has been shown to
be a risk factor for the development of bone marrow lesions in asymptomatic
individuals43.
This is another area where future research may help elucidate how aging changes
in a tissue outside of cartilage contributes to the risk of OA progression in
older adults.
Finally,
calcification and crystal formation within joint tissues are common findings in
older adults that may play a role in OA progression. The association between
calcium pyrophosphate deposition disease (CPPD) and the presence of
radiographic osteoarthritis has been well established35,
44;
however, the role of calcium crystals in the progression of OA has been
debated. Some believe that OA and CPPD are common but separate age-related
conditions and others believe that the two are closely connected35,
45,
46.
Since OA and calcium pyrophosphate are equally associated with osteophyte
formation, it has been suggested that mechanical stress may induce release of chemokines
which encourage both proliferative bone changes and calcium pyrophosphate
formation47,
48.
Crystals within the articular cartilage or in the synovium could stimulate
toll-like receptors on chondrocytes and synovial cells resulting in production
of inflammatory mediators49.
Crystals may play a role in erosive OA, a more destructive form of OA seen most
commonly in the distal digits of the hands in elderly women in which
inflammation is a prominent component50,
51.
The Contribution of Aging in Cells and Tissues to the
Development of OA
Cell Senescence
Most
of the work to date on the relationship between aging changes at the cellular
level and the development of OA has focused on the articular cartilage. Given
the similarities between chondrocytes and meniscal cells these studies probably
also relate to aging in the meniscus but more studies need to be done in that
specific tissue. Normally there is little to no cell turnover in adult
articular cartilage52
and so chondrocytes are thought to be long-lived cells and as such can
accumulate age-related changes over many years. In many tissues, senescent
cells can be replaced by differentiation of cells from a local pool of
progenitor cells but in adult articular cartilage it is not clear if such a
pool exists. Recent studies have challenged the notion that cartilage does not
contain progenitor cells but these studies were performed with either bovine
tissue from very young animals53
or OA tissue54,
the latter of which might have included cells from other tissues such as the
synovium or bone marrow which can make their way to the cartilage when it is
severely damaged. Even if there is a local pool of progenitor cells, they do
not appear to be capable of replacing senescent, damaged, or dead cells in the
articular cartilage.
There
does appear to be an age-related reduction in the number of chondrocytes in
cartilage and a further loss of cells in OA cartilage but the extent of cell
death is debated16,
17,
55.
A 30% fall in cell density between the ages of 30 and 70 years has been
described in human hip specimens56.
However, a study of human knees found less than 5% cell loss with aging52.
Although many studies have reported apoptotic chondrocytes in OA cartilage17,
few have examined apoptosis in cartilage with normal aging with the exception
of a study in rat cartilage that found evidence of increased apoptosis with
aging57.
An age-related decline in levels of the high-mobility group box (HMGB) protein
2, which is expressed in the superficial zone of cartilage, might contribute to
an increase in chondrocyte death58.
HMGB2 is a nonhistone chromatin protein that can serve as a transcriptional
regulator. Deletion of HMGB2 in transgenic mice was found to cause an early
onset of OA-like changes in the superficial zone of cartilage that were
associated with an increase in susceptibility of chondrocytes to cell death.
Chondrocytes
have been shown to exhibit telomere shortening59,
a classic feature of cell senescence, but since chondrocytes rarely divide it
is unlikely that the shortened telomeres represent replicative senescence.
Classic replicative senescence requires over 30-40 population doublings60
which would be unlikely to occur in adult cartilage. Telomere shortening can
also occur from extrinsic or “stress-induced” senescence that results from the
chronic effects of oxidative damage, activated oncogenes, and inflammation61,
62.
This form of cell senescence is much more likely in cartilage, where oxidative
stress and chronic inflammation could be factors63.
The
concept of cell senescence has developed beyond classic replicative senescence
which refers to the inability of senescent cells to undergo further cell
division. There is mounting evidence that cell senescence can also result in a
phenotypic alteration of cells called the senescent secretory phenotype62,
64.
This phenotype is characterized by the increased production of cytokines
including IL-1, IL-6, and IL-8, matrix metalloproteinases, and growth factors
such as EGF. The accumulation of cells expressing the senescent secretory
phenotype can contribute to tissue aging and given the increased production of
cytokines and MMPs in OA cartilage may directly link aging to the development
of OA (Table 1). There is evidence for increased MMP-3 and MMP-13 in
cartilage with aging65
as well as an age-related accumulation of collagen neoepitopes representing
denatured or cleaved collagen66,
67.
Cleavage of type II collagen by MMPs has been noted in cartilage from hip
joints of older individuals66
as well as in “normal appearing” knee cartilage taken at autopsy65.
However, since these joints are commonly affected by OA, it is not clear if the
collagen damage represents aging changes, early OA, or a continuum from aging
to OA.
Aging Changes in Joint Tissues and
the Contribution of Aging to the Development of OA.
Cell
senescence in cartilage has been associated with a decline in the ability of
chondrocytes to respond to growth factors and this could be an important
contributing factor to the change in the balance of anabolic and catabolic
activity seen in OA. Key matrix stimulating growth factors in cartilage include
IGF-I, OP-1 (BMP-7), and TGF-β. There is substantial evidence for a decline in
the chondrocyte response to IGF-I with aging68-70
and in chondrocytes isolated from OA cartilage69,
71.
There is evidence that the decline in IGF-I response (or IGF-I resistance) is
due to altered cell signaling. A reduced ability of IGF-I to activate cell
signaling was noted in aging rat cartilage70
and in aged equine chondrocytes72,
73.
Because IGF-I is an important autocrine survival factor in cartilage74
the age-related decline in IGF-I signaling may play a role in age-related cell
death. The expression and amount of OP-1 present in cartilage declines with age75
which may be related to increased DNA methylation at the OP-1 promoter76.
Likewise, levels of TGF-β2 and TGF-β3 (but not TGF-β1) decline with age as does
the level of the TGF-β receptor I and II77.
Similar to IGF-I, age-related alterations in the TGF-β signaling pathway have been
described and these may also contribute to the development of OA78.
Aging in the Cartilage Matrix
Age-related
changes that occur in the cartilage matrix can also contribute to the
development of OA. There is evidence from knee MRI studies that cartilage thins
with aging, particularly at the femoral side of the joint79
and at the patella80,
suggesting a gradual loss of cartilage matrix with aging. This could be due to
a loss of cells and the reduced growth factor activity discussed above but
could also be due to something as simple as reduced water content. Articular
cartilage is about 70-80% water. The water content in cartilage is controlled
to a large extent by the presence of aggrecan, a large “aggregating”
proteoglycan found in the cartilage matrix. Aggrecan contains highly sulfated
glycosaminoglycan chains that are negatively charged and therefore very
hydrophilic and are responsible for the resiliency in cartilage. Age-related
changes in the size, structure, and sulfation of aggrecan have been reported81-84
which reduce cartilage resiliency and hydration85.
Perhaps
the best studied aging-related matrix protein modification in cartilage is the
accumulation of advanced glycation end-products (AGEs). AGEs are produced by
the spontaneous nonenzymatic glycation of proteins that occurs when reducing
sugars including glucose, fructose or ribose, react with lysine or arginine
residues86.
Because the articular cartilage has a relatively low turnover rate, it is
particularly susceptible to AGE formation which in other tissues occurs most
commonly in diabetics with chronically elevated glucose levels. Type II
collagen, the most abundant matrix protein in cartilage, has a half-life that
has been calculated to be over 100 years87.
The
accumulation of AGEs in knee cartilage has been suggested to play a role in the
development of osteoarthritis86,
88.
Modification of collagen by AGE formation results in increased cross-linking of
collagen molecules. The most common AGE-related cross link is pentosidine which
has been found to be present in cartilage in increasing amounts with age87,
89,
90.
Formation of excessive collagen cross-links affects the biomechanical
properties of cartilage resulting in increased stiffness making the cartilage
more brittle91
and increasing the susceptibility of the tissue to fatigue failure89.
Increased levels of AGEs in cartilage have also been associated with a decline
in anabolic activity92.
Although reported in a small study that used tissue removed at the time of
joint replacement, amyloid has been detected in meniscal tissue from older
adults93
suggesting additional age-related matrix changes may play a role in the
development of OA.
The Role of Age-related Oxidative Stress and Oxidative Damage
in OA
The
theory that aging changes in tissues are the result of oxidative damage from
the chronic production of endogenous reactive oxygen species (ROS) or “free
radicals” was proposed in the 1950's94
and is still relevant to aging in joint tissues such as the articular
cartilage. Human articular chondrocytes actively produce several different
forms of ROS including superoxide, hydroxyl radical, hydrogen peroxide, as well
as reactive nitrogen species, most notably nitric oxide95-97.
Increased levels of intracellular ROS were recently detected in cartilage from
old when compared to young adult rats98.
Normally the levels of ROS are controlled by the balance of ROS production and
the presence of various anti-oxidants. Glutathione is an important
intracellular anti-oxidant and when levels of ROS are in excess the ratio of
oxidized to reduced glutathione is changed. Previous studies have detected an increase
in oxidized glutathione with age in chondrocytes isolated from normal ankle
tissue99.
There is also evidence that levels of anti-oxidant enzymes, including catalase
and superoxide dismutase, are present at lower levels with aging98,
100
and in OA cartilage101.
Because
of the slow turnover of cells and matrix in cartilage, it is likely that damage
from excessive ROS would accumulate over time. Evidence for oxidative damage in
articular cartilage was provided by a study showing increased nitrotyrosine (a
measure of oxidative damage to proteins) with aging, as well as with OA102.
Increased levels of ROS can result in DNA damage which has been noted in OA
cartilage103
including in mitochondrial DNA104.
This can affect cell viability and matrix production. Oxidative stress can also
contribute to the senescent phenotype of chondrocytes105.
The resistance to IGF-I noted in aging and OA chondrocytes may also be related
to excessive levels of ROS that have been shown to interfere with normal IGF-I
signaling resulting in reduced matrix production106.
This could also occur indirectly by the production of oxidized low-density
lipoproteins in cartilage which can in turn contribute to chondrocyte
senescence and reduced chondrocyte signaling107.
An
aging-related increase in ROS levels could play an important role in the
development of OA108.
The various inflammatory mediators found to be increased in OA, including IL-1,
IL-6, IL-8, TNF-α, and other cytokines can all stimulate the further production
of ROS and ROS in turn can be involved in the increased production of MMPs109.
In support of a role for ROS in the development of OA, the use of several
anti-oxidant vitamins along with selenium (a glutathione peroxidase co-factor)
was shown to reduce the development of OA in a mouse model110,
N-acetylcysteine (NAC) reduced cartilage destruction and chondrocyte apoptosis
in a rat OA model111
and in impact-loaded osteochondral explants112
and low intake of anti-oxidant vitamins has been associated with OA progression
in humans113.
But we still have much to learn about ROS and oxidative stress in aging and OA
in order to define more specific targets. In human clinical trials of chronic
age-related diseases, the use of general anti-oxidants or anti-oxidant vitamins
has had modest or no benefit. Defining the specific mechanisms by which ROS
act, including their role in the regulation of cell signaling, should provide
novel and more specific targets for therapies that would represent an advance
over non-directed treatment with general anti-oxidants.
Conclusion
In
summary, age is a primary risk factor for the development of OA, likely due to
aging changes in cells and tissues that make the joint more susceptible to
damage and less able to maintain homeostasis. OA is characterized by an
imbalance between catabolic and anabolic activity driven by local production of
inflammatory mediators in the cartilage and surrounding joint tissues. The
senescent secretory phenotype likely contributes to this imbalance through the
increased production of cytokines and MMPs and a reduced response to growth
factors. More information is needed to better understand how aging changes in
the bone, meniscus, and ligaments contribute to the development of OA.
Oxidative stress appears to play an important role in the link between aging
and OA. Understanding the basic mechanisms by which excessive ROS affect cell
function at the molecular level may provide the knowledge needed to develop
novel preventative treatments for OA.
Acknowledgments
This
work was supported by the National Institute on Aging (RO1 AG16697 and the Wake
Forest University Claude D. Pepper Older Americans Independence Center P30
AG021332), the National Institute on Arthritis, Musculoskeletal and Skin
Diseases (RO1 AR49003), the American Federation for Aging Research, and the
Dorothy Rhyne Kimbrell and Willard Duke Kimbrell Professorship.
Footnotes
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