PREVIOUS SUCCESS STORIES
Molly is a 10 year old spayed female Boston Terrier owned by Linda of San Antonio, TX. Molly was diagnosed with autoimmune hemolytic anemia on December 30, 2001.
When Linda was asked to describe Molly's symptoms prior to her AIHA diagnosis she replied, "Molly has always been such a sweet spirit. If there was one way to describe her it would be "fun". She was always ready to play ball at the drop of a hat. We knew she was ill when she showed no interest in playing ball and she became withdrawn. Molly literally became ill overnight, with no warning whatsoever. Her gums were pale and she was lethargic. We noticed that she seemed jaundiced and became concerned that she may have some sort of liver ailment."
Linda continued, "We took Molly to the vet immediately and he seemed to know just by looking at her that she had AIHA. He, of course, confirmed this with tests. Her PCV at that time was 17. Molly was hospitalized and treatment was begun with 20 mg Prednisone and IV fluids. Her PCV dropped to 12 overnight and she was then transfused. The transfusion lifted her PCV to 25, however, it plummeted to 10 overnight. Her vet, then, suggested a splenectomy. We agonized over that decision, however, I just couldn't put her down when every time we visited she would wag her tail and she would eat for me. Molly had her spleen removed on January 3, 2002. The Coombs test on the spleen was positive. Following the splenectomy Molly was transfused with Oxyglobin and placed on 1cc of Cyclosporine, 20mg of Prednisone, and 12.5 mg of Imuran as well as Tagamet for stomach protection. Her PCV improved to 22 and she was allowed to go home one week after the onset of her illness. She began a slow recovery process and over the course of the next couple of months her Prednisone was gradually decreased and finally discontinued. She remained on the Cyclosporine and Imuran. Over the course of the third month, her Cyclosporine dosage and frequency was gradually decreased and discontinued as she maintained her PCV. She remains on 12.5 mg Imuran per day at his time. Molly had a few stomach upsets early on, due to the Prednisone and those were treated effectively. Molly takes Heartgard for heartworm protection and Advantage for flea prevention. Because of Molly's bout with AIHA, we do not plan on vaccinating her again."
When Linda was asked to comment on the current state of Molly's health she replied, "Molly has made a remarkable recovery. She is her old self again, playful, happy and full of energy. Her last blood test on October 17, 2003 revealed a PCV of 41 and this number has been typical for Molly over the past year. If Molly had a theme song it would be "Girls Just Want to Have Fun". She has always been a very energetic, happy and affectionate little dog, thankfully, she has regained all of these qualities along with her health. Molly is beginning to show a few signs of aging (opacity of the eyes and a little more gray hair), but she hasn't let that slow her down one bit - there is nothing she enjoys more than rousing game of fetch the ball. She continues to maintain a steady average PVC of 40 and her platelet count remains stable. Our Molly is a once in a lifetime dog. She is very special to us and has a special bond with our daughter, Megan. We are so grateful that she continues to thrive and we look forward to many more years with our beloved Molly."
Molly Update, October, 2005
I recently received the following email from Linda.
“I wanted to let you know that our dear Molly died peacefully yesterday afternoon. She went to sleep and didn’t wake up. We were so blessed to have had the additional time with her after her amazing recovery from AIHA. She lived almost 4 years following her initial diagnosis, without a relapse. She had been to the vet a few days before her death and all her blood tests came back normal. She was just slowing down a little due to age (cataracts and a touch of arthritis), but still our lovable Molly. We will miss her very much.”
Gizmo is a 5 year old neutered male Shih Tzu/Poodle mix owned by Liz and Mark of Glasgow, KY. Gizmo was diagnosed with autoimmune hemolytic anemia on October 11, 2002.
When Liz was asked to describe Gizmo's symptoms prior to being diagnosed with AIHA she replied, "he became very lethargic and was not eating well. Prior to this Gizmo was vibrant, energetic and full of life. He loved walks, squeaky toys and playing with his girlfriend, Zoe. We became concerned when he tired easily and expressed little interest in toys or walks. He also became unable to jump up on the bed so we had to provide him with a stool to get up there."
Gizmo was taken to the vet who immediately suspected AIHA. Even though AIHA was suspected the vet did a number of tests including tests for lead, Rocky Mountain Spotted Fever and Ehrlichia, all of which came back negative. Prior to results of the Coombs test and AIHA diagnosis, Gizmo had a PCV of 16.5 and was started on 10 mg prednisone twice per day. By the time the results of the Coombs test came back, positive, Gizmo's PCV had dropped to 10. A blood transfusion was administered and the prednisone was increased to 20 mg twice per day. On October 24, 2002, 12.5 mg Imuran per day was added to the treatment regimen. A bone marrow biopsy was preformed in November 2002, which had inconclusive results. Later the internal medicine specialist performed a bone core biopsy. The results of this biopsy indicated, "findings compatible with a regenerative anemia." On December 2, 2002 Imuran was discontinued and 12.5 mg Cytoxan (cyclophosphamide) was started. The Cytoxan was given on Mondays, Tuesdays and Wednesdays. Danazol was also added to the treatment regimen on December 2, 2002.
As Gizmo's PCV continued to rise, the drugs were slowly decreased. The Danazol was discontinued on February 28, 2003. On March 4, 2003 the Cytoxan was reduced to Mondays & Tuesdays, and on July 15, 2003, the Cytoxan was reduced to Mondays only. The Cytoxan was discontinued on August 6, 2003. The prednisone was slowly tapered down over 13 months until by November, 2003 it was being given at a dosage of 5 mg once per week and then totally discontinued in December, 2003. Gizmo is currently taking no medications for the treatment of AIHA. He takes one Pet Tab (a vitamin/mineral supplement) per day. Interceptor is used for heartworm protection and Frontline is used for flea and tick control when necessary. In addition, Liz bathes Gizmo in Royal Chrysanthemum shampoo which according to her is " a natural flea/tick shampoo." Gizmo has received no vaccinations since his AIHA diagnosis.
When Liz was asked to comment on the current state of Gizmo's health, she replied, "Gizmo is doing well. He is almost back to his old self except for being a few pounds heavier and a little sparser in the hair department. His last CBC on January 20, 2004 revealed a PCV of 54, with all other readings in the normal range. If he isn't bouncing around squeaking his favorite toys, he is snuggled up on the couch with us. Gizmo was the spoiled rotten only child, now I guess you would call him impossibly spoiled. He is always getting hugs from his "mom and dad." At the time of the AIHA diagnosis, Mark and I were devastated, but dealing with this has strengthened our bond with Gizmo. He is such a blessing and we are grateful for every day God has granted us with him."
Toby is a 5 year old spayed female Pembroke Welsh Corgi owned by Ann and Keith of State College PA. Toby was diagnosed with immune-mediated hemolytic anemia on July 18, 2002.
When Ann was asked to describe Toby's symptoms prior to her IMHA diagnosis she replied, "on July 17, 2002, she collapsed on the floor and appeared to have a small seizure. She experienced extreme listlessness and lethargy as well as had no appetite or interest in her surroundings. She also started hiding from the family. Later she was unable to stand and was urinating blood-tinged liquid. In addition we noticed labored breathing and white gums. We also saw Toby starting to become jaundiced with a slight yellow appearance to her eyes. By the time I took her to the vet she was so weak, she had to be carried."
Toby was taken to her local vet who quickly diagnosed her with IMHA. His diagnosis was based on her symptoms as well as an enlarged spleen and elevated temperature. A CBC was done which revealed a PCV of 14 and a blood smear indicated a number of spherocytes. Toby was noted to have both intravascular and extravascular hemolysis. The veterinarian gave Toby injections of Dexamethasone and advised Ann and Keith "to take her to the Veterinary hospital at the University or Pennsylvania (VHUP) or Cornell immediately or she would die." Ann commented, "we chose to go to VHUP which is 200 miles from our home. Before we left we were given one bag of Oxyglobin to help Toby survive the 3-3 ˝ hour trip. Our vet also gave us a portable oxygen tank to use on the trip if Toby got into trouble and her breathing became more labored. We laid Toby on the front seat right in front of the air-conditioning fan and started on the trip to VHUP. We arrived there 3 hours later, confused and panic stricken at the events that had transpired in such young dog in such a short time."
Upon arrival at VHUP Toby was admitted to the intensive care unit where a complete workup including an abdominal ultrasound, chest x-rays, extensive blood work (CBC, Coombs test, tick disease panel) and bone marrow aspiration were done. The CBC revealed Toby's PCV had dropped to 10 and the Coombs test was +6. VHUP confirmed the diagnosis of IMHA. During the two weeks Toby was at VHUP she was given four transfusions of packed red blood cells and treated with cyclosporine, prednisone, Mycophenolate (Cell Cept) and heparin. According to Toby's discharge papers from VHUP, "Even though Toby was maintained on injections or continuous infusions of heparin (an anti-clot medication) it is believed that Toby formed a blood clot which then went to her lungs and caused her to have difficulty oxygenating well. X-ray's which were taken at this time, supports this. This is one complication with prolonged or high doses of steroids." Toby was released from VHUP on August 1, 2002 on the following medications; Baytril 68mg, one tablet twice daily, Clavamox 250 mg, one tablet twice daily, Cyclosporine 25 mg, 3 capsules twice daily, Heparin 1000 units/ml, 1.4 mis (1400 units) by subcutaneous injection three times a day, Mycophenolate 250 mg, one capsule twice per day, Pepcid 10 mg, 1 tablet twice daily and Prednisone 20 mg, 1 tablet twice per day. Toby's discharge papers from VHUP contained the following statement, "Toby's IMHA was more difficult to treat than most cases. She was refractory to conventional treatments and it looks as though she has finally started to respond."
According to Ann, "Toby's medication reduction was slow. The medication reduction started on September 5, 2002 when Toby had a PCV of 36 and had been at that number for more then 2 weeks. At that time the prednisone was reduced by 25%. The next drug to be reduced was Mycophenolate, then Cyclosporine, then prednisone again. The medication reduction was done with increments of 2 weeks or longer between each reduction during which time the PCV remained the same or increased. Only one medication was reduced at a time and that reduction was 25%. The last drug to be discontinued was the prednisone which was down to 5 mg every other day and then 5 mg every third day before it was totally discontinued. Our vet continued in contact with VHUP and did CBC's with differentials every 7-10 days through September 20, 2002, then alternated 7-10 days with either a CBC or PCV. After December 6, 2002 we did just the PCV with only an occasional CBC. Toby is currently on no medications for the treatment of IMHA. She will never be vaccinated again. We use Interceptor for heartworm protection and Frontline Plus for flea and tick control, staggering the medications every two weeks."
When Ann was asked to comment on the current state of Toby's health she replied, "She is currently doing quite good. Her last PCV on February 26, 2004 was 59. My vet indicates this number is high normal. We find it unbelievably wonderful!!!! While Toby is overweight due to the long term use of prednisone, she is active, and overall has a cheerful attitude. She has a good quality of life. With swift medical intervention, good follow-up, many prayers and hope, Toby was able to beat the powerful monster of IMHA. The dark veil of IMHA slowly lifted and underneath it my Corgi began to slowly reappear. We will remain ever grateful."
Bushmaster's Recon Scout, affectionately known to his family and friends as "Scout" is a 7 ˝ year old neutered male Shih Tzu owned by Susan and Dennis of Burlington, KY. Scout was diagnosed with autoimmune hemolytic anemia on May 11, 2001.
When Susan was asked to describe Scout's symptoms prior to being diagnosed with AIHA she replied, " the disease appeared to come on very quickly - within 24 to 48 hours. Before Scout's illness he was a well-behaved, voice command trained, loyal dog. After the onset of the AIHA, Scout had no appetite, he became very lethargic and wanted to hide. He acted as though he might be physically hurt and he became so weak that he was unable to stand long enough to relieve himself."
Scout was taken to his veterinarian where a CBC revealed a PCV of 7. Susan commented, "the vet immediately suspected AIHA and was surprised Scout was still conscious with such a low PCV. Since our vet was experienced with AIHA he began treating Scout for it even before the diagnosis was confirmed." Scout was started on injectable Baytril and Vetalog (a glucocoritcoid agent similar to prednisone but with greater potency and duration of effect). According to Susan, "By the next day, when the AIHA diagnosis was confirmed, Scout's PCV had dropped so low that he was unconscious." Scout was given a blood transfusion and started on Dexamethasone injections, prednisolone acetate injections and the antibiotic, Baytril. On May 14, 2001, after being hospitalized for three days, Scout was released from the veterinary hospital with instructions that he be given 10 mg prednisolone AM and PM. According to Susan, "once Scout came home he started to eat better but his appetite was still not back to normal." By May 25, Scout was starting to become more active and on June 6, 2001 he had a PCV of 34. As Scout's PCV continued to rise, the prednisolone was slowly reduced. The slow prednisolone reduction continued until the drug was discontinued entirely several months later.
When Susan was asked to comment on the current state of Scout's health, she replied, "Scout is healthy and back to his old self except for some dental problems which necessitated cleaning and some extractions. He is currently on no medication for the treatment of AIHA and his PCV at his last blood check was 44. He is active for his age and loves to go for walks. It took Scout 18-24 months to shed all the weight he gained while on prednisolone but now his weight remains fairly constant at 12 lbs. Scout is one of three Shih Tzus in our family and his litter mate, Skittle, is his constant companion. Our third Shih Tzu, Snickerdoodle, is 2 years old and still very much a puppy. Both Scout and Skittle find themselves annoyed with Snicker's puppy antics from time to time. For a while, Scout wanted nothing to do with the newcomer, but he has come to accept him and we are often surprised to see them napping together. Scout is the best natured of the three dogs and extremely tolerant of our overly affectionate 4 year old son who just adores him. Ironically, Scout was named for his adventurous spirit as a puppy, but now is very content to snuggle up to whoever is on the couch or cuddle up to you when you are sleeping. I would urge people to remember, there IS hope when dealing with AIHA. Scout was in a coma and terribly close to death when he was transfused with blood from our vet's albino Doberman. By the end of his transfusion, he was awake, alert and sitting up. We have joked ever since that Scout in now part Doberman. During the 3 days Scout was at the vet's, we visited him to touch & cradle him several times every day. We brought our children and Skittle, Scout's litter mate, to visit as well. It was our vet's opinion that this helped along with the treatment. To look at Scout now, you would have no idea that at one time he was so close to death. Scout holds a special place with our veterinarian - he is one of his best and most famous success stories."
Scout Update, June, 2007
Susan emailed recently with the following Scout update.
"Scout celebrated his 11th birthday on June 18th 2007. Except for being a bit overweight, he has been doing fine. To date he has had no relapses. In December 2005, Scout underwent surgery to remove a bladder stone and came through the surgery with flying colors. He is now on a special diet to help prevent any future stones from developing.
"Even though Scout is 11 years old, he still enjoys romping with his litter mate, Skittle and our daughter’s 5 year old Shih Tzu, Snickerdoodle. While Scout and Skittle were reluctant to accept Snickers for a while, the three have become good friends. Scout has recently taken up 'singing' with his two buddies. It used to be that the three dogs would only sing in 'private' when they thought no one was home to hear them. However, rather than barking to greet visitors or strange noises, they now have gone 'public' and join in chorus whenever something needs to be announced."
Scout Update, September, 2011
I recently received the following Scout update from Susan.
”I wanted to let you know that our Scout made his journey to Rainbow Bridge today. He was 15 years old. His health and physical condition has been failing in the past several months. However, throughout his life, he never had a relapse of AIHA. It has been a difficult day for us but we are blessed with many happy memories. Scout will always be in our hearts.”
Ch. Gazon Eye Have A Dream, AX, AXJ,CGC, affectionately known as "Marty" to his family and friends is a 6 year old neutered male, American Cocker Spaniel owned by Karon of Stillwater MN. Marty was diagnosed with autoimmune hemolytic anemia on May 6, 2000.
When Karon was asked to describe Marty's symptoms prior to his AIHA diagnosis she replied, "he was very listless and panted heavily. He wanted to lay on his bed and could hardly get up. We thought he was suffering from heat stroke since he had an agility class that night and it was very hot and humid."
Marty was taken to his local veterinarian where blood testing revealed a PCV of 25, pale mucus membranes, capillary refill time (CRT) 1.5 and a temperature of 103.0. His urine was brown and the CBC showed his blood was auto agglutinating. Marty was hospitalized at the veterinary clinic for 3 days during which time he was given Lactated Ringers Solution, subcutaneously (SQ), Amoxicillin SQ, Dexamethasone, intramuscularly (IM) and Baytril IM. When Marty was released from the veterinary clinic Karon was instructed to give him 20 mg prednisone and 200 mg amoxi-tabs per day. Karon commented, "During the next month the vet reduced the prednisone each time the PCV increased and by Friday June 2, 2000, when Marty's PCV was up to 41 the prednisone was down to 5 mg. Since we were getting ready to leave for an agility trail in Iowa that day, I questioned the vets decision in regard to the latest prednisone reduction. He felt Marty was doing fine."
Karon continued, "we went to the agility trial as planned. Marty was playful all weekend and ate well. Sunday morning it was raining and he stayed in his crate in the vehicle while I ran the other 3 dogs. At about 11:30 AM, when I was ready to head home, I took Marty out of his crate to let him go to the bathroom and he could hardly stand up on his own. A vet from Iowa that I was acquainted with came and looked at Marty and even though Marty's pulse was strong, she felt he was crashing quickly. She thought I could make it home OK, so with the other dogs settled in their crates and Marty on a cushion on the front seat, breathing very labored, I prayed all the way home. He never lifted his head up once. I had called my vet from Iowa advising him of the situation and he said to bring Marty in first thing in the morning. When we got home and I carried Marty outside, and saw how weak he was getting I went immediately to the Animal Emergency Clinic near my home. Upon admission to the Emergency Clinic Marty's PCV was 12, weight 21.7 pounds, Temp. 103.4, Pulse 200, Respiration 50, mucous membranes very pale, CRT >2 seconds. Marty was given 30 mg prednisone through an IV catheter and a 25 cc/hr drip of Oxyglobin was started. Later in the evening, 100 mg IV Cytoxan was given. At 10 PM Marty's temp was 102.7, pulse 135, respiration 40, PCV 10.5. The doctor noted, 'I know this may not be completely accurate post-Oxyglobin, but Marty seems to be fairly perky, he walked outside with a kick to his step and urinated and he ate very well. Started a new bag of Oxyglobin.' At 2:20 AM Marty's PCV had dropped to 7. The doctor noted, 'Oxyglobin done, Again outside to urinate. Seems to be feeling pretty good despite downward trend of PCV, ate well'.
Before Marty was released from the Emergency clinic on Monday morning, he was given 20 mg prednisone. I was referred to the University of Minnesota (U of MN) where we went immediately. On admission to the U of MN, Marty's PCV was 7 and the vet offered me very little hope of him surviving. She advised me AIHA is a very expensive illness to treat and there was no guarantee he would even recover. In addition she told me if I felt treating Marty was going to be a financial burden the best thing to do was to euthanize him. My husband was away, so I had to make the decision on my own to try to save Marty. He was a breed champion, only 2 years old, and such a sweet pet, I felt I owed it to him to at least try. The vet did assure me if Marty came through this he could resume a normal life. Marty spent 8 days in ICU at the U of MN. While there, he received a transfusion of packed RBC's three times and was on Prednisone. He did not respond to treatment at first. He was then started on Imuran and finally his PCV started to improve. Marty was released from the U of MN on June 13, 2000 on 12.5 mg Imuran daily, 15 mg prednisone morning and evening and 1000 U/ml heparin injected under the skin every 8 hours for the first 3 days (this decreased with each subsequent dose). The doctors comments on Marty's release from the U of MN were: 'Good prognostic factors for Marty include the initial mild degree of anemia last month, the rapid response to a low dose of prednisone last month, and the lack of significant complications. The timing is suspicious for a vaccine related IMHA, which tends to be associated with a better outlook. Poor prognostic indicators for Marty include the fact that this is technically a recurrence of the hemolysis (although since his initial treatment was very non-aggressive, this may be a continuation of the initial episode), the apparent intravascular hemolysis (as indicated by the red urine and serum prior to Oxyglobin administration), the initial auto agglutination (although he doesn't have this now), and the fact that he is a Cocker Spaniel. Overall, I think his prognosis is fair to good with long term aggressive immunosuppression'."
Over the next couple of years Marty was weaned off prednisone completely while he continued on Imuran every other day. When he had a set back which the doctor felt was from the Imuran it was discontinued and the prednisone was started again. Marty was on varying doses of prednisone, no more than 20 mg a day and as little as 2.5 mg every other day (eod) until he was on a maintenance dose of 2 ˝ mg eod.
Karon noted, "a few months ago I was going to the U of MN with one of my Cockers who has Cushings and decided to take Marty along, since it was nearly time for him to go for blood work. His PCV was 37.8 while his platelets were 374,000. The vet said we should retest in a week since perhaps it was just a bad draw. We tested a week later and his PCV had gone up to 43 but his platelets had dropped to 44,000. The vet said apparently the 2.5 mgs of prednisone he was on was not enough to keep him in remission so we immediately increased the prednisone to 20 mg a day for 2 weeks and retested. His PCV was 40, down a bit but still in the normal range, but his platelets had gone up to 595,000. We have since gradually decreased the prednisone till at the present time it is at a dosage of 5 mg per day. I assume at some point we will decrease the prednisone to 5 mg every other day, however, I am in no hurry for that reduction to happen."
When Karon was asked to comment on the current state of Marty's health, she replied, "he is doing well. His last blood check was on April 20, 2004 at which time his PCV was 42 and his platelets were 364,000. I am optimistic about Marty's continued recovery and have entered him in a local agility trial on May 7th & 8th. We have had a bad few months but I hope Marty will soon be back to normal. We had to pull him from 4 winter agility trials and stop his training classes for the time being, but he has spunk and he'll be back to jumping soon, if not, you may see us in the obedience ring! Marty has a medical file the size of a 15 year old dog, according to the vet, but gosh aren't they worth the struggle and the fight, I sure think so."
Marty Update, June, 2004
Editors Note: On June 12, 2004 I had the great privilege to meet Marty and his owner/caregiver, Karon, at an agility competition. It was such a joy to watch Marty run the agility course and later receive a handshake from him and visit with Karon.
Marty Update, May, 2008
I recently received the following Marty update from Karon.
”Marty will be 10 years old this month as well as an 8 year survivor of AIHA! He continues to be well and has had no related issues for quite some time.
”Marty remains on 5 mg prednisone every other day and has regular blood work done about twice a year. The doctor and I both feel that Marty is tolerating the prednisone well, with no hair loss, or other symptoms associated with long term prednisone usage so he will remain on it for the rest of his life. He is a little forlorn now as we recently lost his special canine buddy, Cedar. Marty no longer has a "pack" and since he's always been a part of one, he doesn't really know what to do! When he see's my son's 2 dogs you can just see him perk up.
”I just wanted to update you on my last remaining little guy! The one we thought would never make 10!!!
Surprises are great!!”
Marty Update, August, 2011
Karon recently wrote with the following Marty update.
”Marty is now 13 years old. This past May, he became an 11 year survivor of AIHA!!! His days consist mostly of sleeping, however, 3 years ago we got him a new little cocker brother, Jake, who will be 4 in November. Marty seemed to miss his pal, Cedar, so much, we thought a new kid in the home would pep him up.
At first Marty seemed more bothered by Jake than anything, but now they are great pals. Since Marty is now deaf and his eye sight is failing, Jake is his seeing eye dog. Whenever Jake gets up or moves around in the house, Marty is not far behind. “
”In June 2008, Marty had a lateral retinacular stabilization on his right stifle to repair his right cranial cruciate rupture. He healed well but lately his left leg has been giving him some problems. Marty continues to eat well. He is still on 5 mg of prednisone every other day and will be so for the balance of his life. He tolerates this low of a dosage of prednisone well. Other than looking frail, Marty’s spirits are good and he continues to be our little couch potato!!”
Marty Update, September, 2011
Karon recently wrote with the following Marty update.
”Today with sorrow in our hearts we sent Marty to the Rainbow Bridge. He was ready, we were not, and we are grieving for him.
”At the veterinary exam today the veterinarian heard fluid around Marty’s heart. Marty had been coughing, off and on, for a while and not wanting to eat at times. We had been softening his food, but since he also had severe periodontal disease (grade 4), I am sure his mouth was sore. Marty lost his hearing around age 9, and his eye sight was failing. He also had pigmentary keratitis of the right eye and cataracts in both eyes. So with heavy hearts we made the decision to let him go before he had a major crisis.
”Marty was an 11 year survivor of AIHA.
He earned the AX & AXJ titles and some legs in Masters before I retired him from agility . Marty was the best couch potato anyone could ever have.
He was also a wonderful traveler, always ready and waiting by the door when he saw us packing the RV, so we wouldn’t get out without him.
”Although the decision, to let Marty go was so very hard, we felt it was the last loving gift we could give our little ‘Mart Man’.”
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