Date:Wed, 1 Jul 2009 13:17:22 +0100
Reply-To:Tom Kindlon <[log in to unmask]>
Sender:ME/CFS and Fibromyalgia Information Exchange Forum
<[log in to unmask]>
From:Tom Kindlon <[log in to unmask]>
Subject:ACT: (Part 2 of 2) Tom Kindlon's submission on the CDC's draft
5-year plan for CFS
(Part 2 of 2) (Tom: below the information on surveys is a little bit of
extra comment on the CDC's plans, for what it's worth)
Surveys from other countries:
The 6 above surveys are from the UK. I have information on some surveys
undertaken by local groups in the UK which would also report high rates of
adverse reactions both from CBT and especially GET.
However reports of adverse reactions are not restricted to the UK.
Gijs Bleijenberg PhD is a Dutch psychologist which the CDC has worked with.
I fear he will not have shared with the CDC or others results of surveys of
patients which show a somewhat different picture to the studies he has
published.
==================
Survey 7:
Koolhaas et al (2008/2009)
*Majority of ME/CFS patients negatively affected by Cognitive Behaviour
Therapy***
(From:
http://listserv.nodak.edu/cgi-bin/wa.exe?A2=ind0803A&L=CO-CURE&P=R647&I=-3 )
To the best of my knowledge, this was presented at the 2009 IACFS/ME
conference by Dr Van Hoof.
The following summary is from page 4 of the Dutch-language study.
http://home.planet.nl/~koolh222/cgtbijmecvsvanuitperspectiefpatient2008.pdf
Cognitieve gedragstherapie bij het chronische vermoeidheidssyndroom (ME/CVS)
vanuit het perspectief van de patiënt
Drs. M.P. Koolhaas, H. de Boorder, prof. dr. E. van Hoof
Date: February 2008
ISBN: 978-90-812658-1-2
The Netherlands
*SUMMARY*
*Background
*In recent years, Chronic Fatigue Syndrome, also known as Myalgic
Encephalomyelitis
(ME/CFS), has been getting a lot of attention in scientific literature.
However its aetiology
remains unclear and it has yet to be clarified why some people are more
prone to this
condition than others. Furthermore, there is as yet no consensus about the
treatment of
ME/CFS. The different treatments can be subdivided into two groups, the
pharmacological
and the psychosocial therapies. Most of the scientific articles on treatment
emphasize the
psychosocial approach.
The most intensively studied psychological therapeutic intervention for
ME/CFS is cognitive
behaviour therapy (CBT). In recent years several publications on this
subject have been
published. These studies report that this intervention can lead to
significant improvements in
30% to 70% of patients, though rarely include details of adverse effects.
This pilot study was
undertaken to find out whether patients' experiences with this therapy
confirm the stated
percentages. Furthermore, we examined whether this therapy does influence
the
employment rates, and could possibly increase the number of patients
receiving educational
training, engaged in sports, maintaining social contacts and doing household
tasks.
*Method
*By means of a questionnaire posted at various newsgroups on the internet,
the reported
subjective experiences of 100 respondents who underwent this therapy were
collected.
These experiences were subsequently analysed.
*Results
*Only 2% of respondents reported that they considered themselves to be
completely cured upon finishing the therapy. Thirty per cent reported 'an
improvement' as a result of the therapy and the same percentage reported no
change. Thirty-eight percent said the therapy had affected them adversely,
the majority of them even reporting substantial deterioration. Participating
in CBT proved to have little impact on the number of hours people were
capable of maintaining social contacts or doing household tasks. A striking
outcome is that the number of those respondents who were in paid employment
or who were studying while taking part in CBT was adversely affected. The
negative outcome in paid
employment was statistically significant. CBT did, however, lead to an
increase in the
number of patients taking up sports.
A subgroup analysis showed that those patients who were involved in legal
proceedings in order to obtain disability benefit while participating in CBT
did not score worse than those who were not. Cases where a stated objective
of the therapy was a complete cure, did not have a better outcome. Moreover,
the length of the therapy did not affect the results.
*Conclusions
*This pilot study, based on subjective experiences of ME/CFS sufferers, does
not confirm the high success rates regularly claimed by research into the
effectiveness of CBT for ME/CFS. Over all, CBT for ME/CFS does not improve
patients' well-being: more patients report deterioration of their condition
rather than improvement. Our conclusion is that the claims in scientific
publications about the effectiveness of this therapy based on trials in
strictly controlled settings within universities, has been overstated and
are therefore misleading. The findings of a subgroup analysis also
contradict reported findings from research in strictly regulated settings.
==============
Survey 8: Survey of 3 Dutch ME/CFS patient organizations (December 2008):
3 Dutch ME/CFS patient organisations published in December 2008 at:
http://www.nivel.nl/pdf/Rapport-draagvlakmeting-CVS-ME-2008.pdf the results
of a large survey they undertook. Following the link, one can see the
questionnaire that was used.
Table 2.1 numbers of sent questionnaires and responses returned to the
patients' associations
Number sent: 740
Total number of responses: 449
% response rate (gross): 60.7%
Number of filled in questionnaires: 412
% Net response rate: 55.7%
~~~~~~~~~~
(Rough) Translation into English of the results tables from a large survey
of the membership of three Dutch ME/CFS patient organisations (part 2 of 2)
Table 4.10 Treatment or accompaniment/support/management concerning the
diagnosis ME/CFS and the impact experienced of that treatment or
accompaniment/support
Treatment or accompaniment/support/management
Column 1: % that has had (the) treatment
Column 2: Number of those that have answered
Column 3: Impact: After (i.e. because of) the treatment, improved
Column 4: No impact
Column 5: Impact: After (i.e. because of) the treatment, disimproved
- Diet 65,2% n=251 50,2% 43,8% 6,0%
- Homoeopathy 64,6% n=247 30,8% 62,8% 6,5%
- Physiotherapy 52,4% n=203 36,9% 41,9% 21,2%
- Vitamin B12 48,2% n=184 32,1% 63,0% 4,9%
- Psychotherapy (not CBT), Psychological support 46,1% n=169 33,1%
60,9% 5,9%
- Management based on trying to have a balance of rest and activity 44,2%
n=172 57,0% 33,7% 9,3%
- Antidepressants 43,0% n=165 32,7% 36,4% 30,9%
- Carnitine 40,9% n=156 37,2% 53,8% 9,0%
- Melatonin 38,0% n=146 32,9% 50,7% 16,4%
- Graded Activity/Exercise Therapy 37,3% n=142 43,0% 23,9% 33,1%
- Painkillers 37,0% n=138 47,1% 47,8% 5,1%
- Cognitive Behavioural Therapy (CBT) 29,9% n=115 30,4% 42,6% 27,0%
- oefentherapie (I think this is a cross between physiotherapy and the
Alexander Technique) 27,0% n=102 20,6% 42,2% 37,3%
- Herbal Medicine 26,7% n=97 28,9% 61,9% 9,3%
- Bed-rest 11,7% n=45 48,9% 44,4% 6,7%
- Participation at a rehabilitation centre 10,2% n=40 45,0% 35,0% 20,0%
- Immunological therapy 7,7% n=25 44,0% 40,0% 16,0%
- Neurofeedback 3,8% n=14 35,7% 57,1% 7,1%
To summarise the data here for GET/GAT, CBT and Physiotherapy in a way that
is easier to read
The results for Graded Activity/Exercise Therapy were:
142 respondents
Improved: 61 (43.0%)
No impact: 34 (23.9%)
Disimproved/Made worse: 47 (33.1%)
Physiotherapy
203 respondents
Improved: 75 (36.9%)
No impact: 85 (41.9%)
Disimproved/Made worse: 43 (21.2%)
Cognitive Behavioural Therapy (CBT)
115 respondents
Improved: 35 (30.4%)
No impact: 49 (42.6%)
Disimproved/Made worse: 31 (27.0%)
~~~~~~~~~~
Tabel 4.10 Behandeling of begeleiding in verband met de diagnose ME/CVS en
het ervaren effect van die behandeling of begeleiding
Behandeling of begeleiding % dat
Column 1: % dat behandeling heeft gehad
Column 2: aantal dat vraag naar effect heeft beantwoord
Column 3: Effect: Het ging daarna beter
Column 4: Geen effect
Column 5: Effect: Het ging daarna slechter
- dieet 65,2% n=251 50,2% 43,8% 6,0%
- homeopathie 64,6% n=247 30,8% 62,8% 6,5%
- fysiotherapie 52,4% n=203 36,9% 41,9% 21,2%
- vitamine B12 48,2% n=184 32,1% 63,0% 4,9%
- psychotherapie (niet CGT), psychologische begeleiding 46,1% n=169 33,1%
60,9% 5,9%
- begeleid zoeken naar een balans van activiteiten en rust 44,2% n=172 57,0%
33,7% 9,3%
- antidepressiva 43,0% n=165 32,7% 36,4% 30,9%
- carnitine 40,9% n=156 37,2% 53,8% 9,0%
- melatonine 38,0% n=146 32,9% 50,7% 16,4%
- begeleide opbouw van activiteiten 37,3% n=142 43,0% 23,9% 33,1%
- pijnstillers 37,0% n=138 47,1% 47,8% 5,1%
- cognitieve gedragstherapie (CGT) 29,9% n=115 30,4% 42,6% 27,0%
- oefentherapie 27,0% n=102 20,6% 42,2% 37,3%
- kruidentherapie 26,7% n=97 28,9% 61,9% 9,3%
- bedrust met begeleiding 11,7% n=45 48,9% 44,4% 6,7%
- opname in revalidatiecentrum 10,2% n=40 45,0% 35,0% 20,0%
- immunologische therapie 7,7% n=25 44,0% 40,0% 16,0%
- neurofeedback 3,8% n=14 35,7% 57,1% 7,1%
Survey 9: Norway (2009)
[Patients' experience with treatment of chronic fatigue syndrome.]
Tidsskr Nor Laegeforen. 2009 Jun 11;129(12):1214-6
[Article in Norwegian]
*Bjørkum T*
*Wang CE*,
*Waterloo K*.
[log in to unmask] Sogndal BUP Postboks 184 6851 Sogndal.
http://www.ncbi.nlm.nih.gov/pubmed/19521443
BACKGROUND: Chronic fatigue syndrome is a highly debated condition. Little
is known about causes and treatment. Patients" experience is important in
this context.
MATERIAL AND METHODS: 828 persons with chronic fatigue syndrome (ICD-10
code: G93.3) were included in the study. They were recruited through two
Norwegian patient organizations (ME-association and MENiN). The participants
filled in a questionnaire on their experience with various approaches to
alleviate their condition.
RESULTS: Pacing was evaluated as useful by 96% of the participants, rest by
97%, and 96% of the participants considered complete shielding and quietness
to be useful. 57% of the participants who had received help to identify and
challenge negative thought patterns regarded this useful. 79% of the
participants with experience from graded training regarded this to worsen
their health status.
Overall, the results were similar, irrelevant of the severity of the
condition.
INTERPRETATION: Most participants in this study evaluated pacing, rest and
complete shielding and quietness to be useful. The experience of the
participants indicate that cognitive behaviour therapy can be useful for
some patients, but that graded training may cause deterioration of the
condition in many patients. The results must, however, be interpreted with
care, as the participants are not a representative sample, and we do not
know the specific content of the approaches.
Survey 10: (US) The CFIDS Association of America 1999 Reader Survey:
The largest survey of ME/CFS patients that I am aware of in the US was
published by the the CFIDS Association of America in 1999 (questionnaires
were also distributed that year).
I can send a copy of the page of results of 28 therapies on request.
Unfortunately, I do not have time to type in all the results at present.
820 readers filled in the questionnaire.
The results for Graded Exercise Therapy were:
462 respondents
Helped a lot: 111 (24.0%)
Helped a little: 170 (36.8%)
No effect: 51 (11.0%)
Harmful: 130 (28.1%).
Numerically this was the highest rate of adverse reactions. Numerically the
second highest rate of adverse reactions was reported for antidepressants:
Antidepressants
539 respondents
Helped a lot: 163 (30.2%)
Helped a little: 154 (28.6%)
No effect: 104 (19.3%)
Harmful: 118 (21.9%).
In terms of percentages, Graded Exercise Therapy had the third highest rate
of adverse reactions. Two treatments, Beta-blockers and colonics, which I
think the CDC is unlikely to recommend, were marginally higher:
Beta-blockers
172 respondents
Helped a lot: 33 (19.1%)
Helped a little: 39 (22.7%)
No effect: 45 (26.2%)
Harmful: 55 (32.0%).
Colonics
131 respondents
Helped a lot: 14 (10.7%)
Helped a little: 38 (29.0%)
No effect: 42 (32.1%)
Harmful: 37 (28.2%).
CBT had a lower rate of adverse reactions compared to the rates seen in
other surveys. This may be because CBT in the US currently is not simply
based on GET – there are different forms offered, some which might encourage
the pacing of activities. However this might change if information from the
form of CBT that tends to be used in the UK and the Netherlands is
highlighted by the CDC.
CBT
160 respondents
Helped a lot: 48 (30.0%)
Helped a little: 60 (37.5%)
No effect: 38 (23.8%)
Harmful: 16 (10.0%).
The treatment with the best results was Pacing of activities. It had the
lowest rate of adverse reactions (1/601 or 0.2%) and the highest helpful
percentage (i.e. the sum of the percentages for helped a little and helped a
lot)
Pacing
601 respondents
Helped a lot: 423 (70.4%)
Helped a little: 167 (27.8%)
No effect: 20 (3.3%)
Harmful: 1 (0.2%).
As I have pointed out, Peter White has strong views on Graded Exercise
Therapy (GET). He has also got strong views against Pacing and at the last
moment resigned from the CMO group on CFS/ME (2002) (mentioned above) as it
had placed Pacing on the same level as GET and CBT. People involved in the
committee were annoyed at this as people had made a lot of concessions to
try to get a document people like him would sign.
This is relevant when one is talking about an “international consensus on
management.” Basically by selecting Peter White for such a committee, it is
very likely that the document will recommend GET with few caveats or
warnings; alternatively Peter White will resign. His views would not be
representative of a lot of the opinions in the UK or internationally, so it
would not really be an international consensus if he was on the sole UK
representative.
As I mentioned before, I believe you need people on any panel who are not in
denial about the adverse reactions from GET (like Peter White appears to
be). Here are my suggestions again: Charles Shepherd MD
[log in to unmask] ; Ellen Goudsmit PhD CPsychol AFBPsS (a
Chartered Health Psychologist) [log in to unmask] ; Abhijit Chaudhuri
DM MD PhD FACP FRCP (a consultant neurologist) [log in to unmask] ; Neil
Abbot MSc PhD (Operations Director, ME Research UK) [log in to unmask]
and William Weir MD (an infectious disease consultant who ran an NHS clinic
for ME for a number of years – I don’t have an E-mail address at the time of
writing but he can be contacted through his practice at: +44-207-467-8478
(i.e. from the US: 00-44-207-467-8478). Without individuals who are willing
to challenge Peter White on such a panel, I believe one is likely to get a
document which hypes the benefits of GET and CBT based on GET and does not
give much if any information on potential risks. To me, this would seem
like a very irresponsible thing for an agency like the CDC to do.
The other point I want to re-iterate is my problems with the way the CDC CFS
team have “operationalized” the Fukuda definition with the “empiric
definition” (Reeves, 2005).
I have previously mentioned virtually all the points I would like to make on
the topic as comments on papers that involved the definition. They are
appended below in green (as they were included in my last submission).
Frustrated with both the lack of feedback and the CDC’s continued use of the
definition, I set up a petition on the issue (see Appendix 1). Despite the
petition’s text not being very “catchy”, there are 1440 signatures.
I am appending the signatures below along with comments they made (more
people me they made comments but for some reason some comments never showed
up – given these are people signing a petition against the definition, these
would not have been positive comments).
As I said in my (written) testimony to the May 2009 CFSAC meeting: “If one
has a heterogeneous group of patients, it can mean that in intervention
trials, if “true” CFS patients only make up a tiny fraction of the cohort,
useful interventions could come up as showing no effect (or even being
detrimental); alternatively, interventions may come up as being useful for
CFS when in fact if one had only looked at those with “true” CFS, the
intervention may have made no difference or may even have been detrimental.”
Given that the CDC is now moving towards intervention studies, this is a
particularly important issue.
The CDC’s response to this criticism might be that using subsets can deal
with this issue. However the definition has been broadened so much by the
empiric definition that it is far from clear that this is enough. The
prevalence rates from CDC CFS studies went up from 0.235% to 2.54%. That
means that on average, patients satisfying the Fukuda definition as the CDC
was previously using it would only make up 9.25% of the patients covered by
the “empiric definition”. And of course due to the nature of probabilities,
the actual figures could well be lower. And even if 9.25% were inducted
into a study, on average in a trial which had at least two “arms”, one of
the arms would have a cohort with less than 9.25% of the individuals
satisfying the Fukuda definition as the CDC was previously defining it. And
of course, even at the earlier stage, it was recognized that even the Fukuda
definition captured a heterogeneous population.
Of course, this point is true in general with the “empiric” definition – the
definition has become so broad that it may now be impossible to find the
subsets that make up CFS.
One other point: as far as I can see, the only virus group specifically
referred to in the CDC’s long 5-year Strategic Plan is HHV6.
It would be good if some of the CDC's (not inconsiderable) CFS research
budget could be used to investigate enteroviruses in CFS. In 2007 a study
involving enteroviruses[4] resulted in much excitement in the media on the
subject. It found, in a sample of CFS patients who had gastrointestinal
symptoms, that 135/165 (82%) biopsies stained positive for VP1 within
parietal cells, whereas 7/34 (20%) of the controls stained positive
(p=<0.001). Earlier studies have demonstrated circulating antigen of
enterovirus, raised antibody titres and viral RNA in the blood and muscle
biopsy specimens of patients with CFS[4-8]. John Chia does recognize that
other infections could be playing a part in some CFS cases but enteroviruses
are by far the most common infection he is finding in his clinic in
California[9].
References
[1] Gelman JH, Unger ER, Mawle AC, Nisenbaum R, Reeves WC: Chronic fatigue
syndrome is not associated with expression of endogenous retroviral p15E.
Molec Diagnosis 2000, 5:155-156.
[2] Vernon SD, Shukla S, Reeves WC: Absence of Mycoplasma species DNA in
chronic fatigue syndrome. J Med Microbiol 2003, 52:1027-1028.
[3] Jones JF, Kulkarni PS, Butera ST, Reeves WC: GB virus-C--a virus without
a disease: we cannot give it chronic fatigue syndrome. Jones JF, Kulkarni
PS, Butera ST, Reeves WC. BMC Infect Dis 2005, 5:78
[4] Yousef GE, Mann GF, Smith DF, et al: Chronic enterovirus infection in
patients with postviral fatigue syndrome. Lancet 1988;1:146-7.
[5] Cunningham L, Bowles NE, Lane RJM, et al: Persistence of enteroviral RNA
in chronic fatigue syndrome is associated with abnormal production of equal
amounts of positive and negative strands of enteroviral RNA. J Gen Virol
1990;71:1399-402.
[6] Galbraith DN, Nairn C, Clements GB: Phylogenetic analysis of short
enteroviral sequences from patients with chronic fatigue syndrome. J Gen
Virol 1995;76:1701-7.
[7] Lane RJ, Soteriou BA, Zhang H, et al: Enterovirus related metabolic
myopathy: a postviral fatigue syndrome. J Neurol Neurosurg Psychiatry
2003;74:1382-6.
[8] Douche-Aourik F, Berlier W, Fe´asson L, et al: Detection of enterovirus
to human skeletal muscle from patients with chronic inflammatory muscle
disease or fibromyalgia and healthy subjects. J Med Virol 2003;71:540-7.
[9] Chia JK, Chia A: Diverse etiologies for the chronic fatigue syndrome.
Clin Infect Dis 2003;36:671-2.
----------------------
Other viruses and microbes are also worthy and studies that involve the gut
may provide more information than studies that just use blood samples.
Thank you for taking the time to read this.
Tom Kindlon
====================
Appendix 1: Petition
http://www.ipetitions.com/petition/empirical_defn_and_CFS_research/index.htm
l
CDC CFS research should not involve the empirical definition (2005)
The petition
We call on the Centers for Disease Control and Prevention (CDC) to stop
using the "empirical" definition[1] (also known as the Reeves 2005
definition) to define Chronic Fatigue Syndrome (CFS) patients in CFS
research.
The CDC claim it is simply a way of operationalizing the Fukuda (1994)
definition[2]. However the prevalence rates suggest otherwise: the
"empirical" definition gives a prevalence rate of 2.54% of the adult
population[3] compared to 0.235% (95% confidence interval, 0.142%-0.327%)
and 0.422% (95% confidence interval, 0.29%-0.56%) when the Fukuda definition
was used in previous population studies in the US[4,5].
The definition lacks specificity. For example, one research study[6] found
that 38% of those with a diagnosis of a Major Depressive Disorder were
misclassified as having CFS using the empirical/Reeves definition.
References
[1] Reeves WC, Wagner D, Nisenbaum R, Jones JF, Gurbaxani B, Solomon L,
Papanicolaou DA, Unger ER, Vernon SD, Heim C. Chronic fatigue syndrome--a
clinically empirical approach to its definition and study. BMC Med. 2005 Dec
15;3:19.
Link: http://www.biomedcentral.com/1...
[2] Fukuda K, Straus SE, Hickie I, Sharpe MC, Dobbins JG, Komaroff A. The
chronic fatigue syndrome; a comprehensive approach to its definition and
study. Ann Int Med 1994, 121:953-959.
[3] Reeves WC, Jones JF, Maloney E, Heim C, Hoaglin DC, Boneva RS, Morrissey
M, Devlin R. Prevalence of chronic fatigue syndrome in metropolitan, urban,
and rural Georgia. Popul Health Metr. 2007 Jun 8;5:5.
[4] Reyes M, Nisenbaum R, Hoaglin DC, Unger ER, Emmons C, Randall B, Stewart
JA, Abbey S, Jones JF, Gantz N, Minden S, Reeves WC: Prevalence and
incidence of chronic fatigue syndrome in Wichita, Kansas. Arch Int Med 2003,
163:1530-1536.
[5] Jason LA, Richman JA, Rademaker AW, Jordan KM, Plioplys AV, Taylor RR,
McCready W, Huang CF, Plioplys S. A community-based study of chronic fatigue
syndrome. Arch Intern Med. 1999 Oct 11;159(18):2129-37.
[6] Jason, LA, Najar N, Porter N, Reh C. Evaluating the Centers for Disease
Control's empirical chronic fatigue syndrome case definition. Journal of
Disability Policy Studies 2008, doi:10.1177/1044207308325995.
Further reading:
Problems with the New CDC CFS Prevalence Estimates
Leonard Jason, Ph.D., DePaul University
tinyurl.com/2qdgu4 i.e.
http://www.iacfsme.org/Issuesw...
Brief comment from Tom Kindlon: I have Chronic Fatigue Syndrome (CFS) for
over 20 years.
I want a lot of research progress in my lifetime and believe the empirical
definition (2005) (also known as the Reeves definition (2005)) decreases the
chances that this will occur: abnormalities that would show up using a more
strictly defined definition won't show up using the empirical/Reeves
definition; and abnormalities that might show up in the broad group covered
by the empirical/Reeves definition are not necessarily representative of CFS
patients.
Similarly treatments that might work on a more strictly defined group of
patients might not show up using the very broad empirical/Reeves definition
and treatments that might appear to work overall on the group defined using
the empirical/Reeves definition might not be suitable for people who satisfy
a stricter definition. This messes up the CFS literature even further.
--
Technical note: I am not sure why some people have grey boxes in the
comments section. Some people have told me they have sent comments that
never went up. I have not idea why this is happening.
Petition sponsor
Tom Kindlon, a patient with Chronic Fatigue Syndrome (CFS) for over 20
years. I have done a lot of voluntary work in the area for over a decade.
Recently I had two letters on CFS published in medical journals.
Links
The paper defining the empirical/Reeves definition can be read at:
http://www.biomedcentral.com/1741-7015/3/19
Some comments on the paper have been posted at:
http://www.biomedcentral.com/1741-7015/3/19/comments
An article by Leonard Jason PhD on the issue can be read at:
tinyurl.com/2qdgu4 i.e.
http://www.iacfsme.org/IssueswithCDCEmpiricalCaseDefinitionandPrev/tabid/105
/Default.aspx
http://me-cfs.se/dok/081205-cfs-no-longer-cfs.pdf
By Kasper Ezelius M.Sc. This includes some links to other definitions,
Kasper's take on the issues and a list of some papers that have involved
using the empirical definition (this list is not up-to-date; virtually all
the papers from the CDC 2-day Wichita study and also from the Georgia cohort
have used the empirical definition to define CFS)
http://www.ipetitions.com/petition/empirical_defn_and_CFS_research/signature
s-1.html
(Included the 1440 signatures and comments)
(I also included the text of my previous submission below this in green)
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