The Danger of an Attack on Piracy Online


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Source: nEW YORK TIME
THE MEDIA EQUATION

The Danger of an Attack on Piracy Online

By invoking the acronym SOPA right at the get-go, I may be daring many of you to check the next column over for something a little less chewy. After all, SOPA, which stands for Stop Online Piracy Act, sounds like a piece of arcane Internet government regulation — legislation that entertainment companies desperately care about and that leaves Web nation and free-speech crusaders frothing at the mouth. The rest of us? What were we talking about again?

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SOPA deals with technical digital issues that may seem to be a sideshow but could become crucial to American media and technology businesses and the people who consume their products. The legislation is the rare broadly bipartisan piece of apple pie. The House Judiciary Committee is expected to resume hearings on it this month and all indications are that it will approve the measure, setting up a vote in the full chamber. The Senate is also expected to vote on its own version of the bill when it returns from the holiday break.
Virtually every traditional media company in the United States loudly and enthusiastically supports SOPA, but that doesn’t mean it’s good for the rest of us. The open consumer Web has been a motor of American innovation and the attempt to curtail some of its excesses could throw sand in the works of a big machine on which we have all come to rely.
Rather than launch into a long-winded argument about why the legislation is a bad idea — it is, as currently written — I thought it might be worthwhile to boil SOPA down into a series of questions.
A NONEXISTENT PROBLEM? Hardly. Regardless of what Web evangelists tell you, SOPA is an effort to get at the very real problem of rogue Web sites — most operating from overseas — offering illicit downloads of movies, music and more. The Motion Picture Association of America cites figures saying that piracy costs the United States $58 billion annually.
Mark Elliot, an executive from the U.S. Chamber of Commerce, said in a letter to The New York Times that such piracy threatened 19 million American jobs. Those figures surely include some politically motivated hyperbole, but anybody who has spent time around a twentysomething consumer knows that piracy is a thorny fact of life for content companies.
In an effort to stanch the flow, on Oct. 26 Representative Lamar Smith, Republican of Texas, introduced the legislation that has come to be known as SOPA. The Senate version,called the Protect IP Act, is seen by tech companies as less onerous because it targets domain name providers and ad networks and not Internet service providers. Both bills seek to create remedies to pirated content because most of the foreign-based sites operate outside of the United States’ legal system.
WOULD IT FIX THE PROBLEM? Probably not, and even if it made some progress toward reining in rogue sites, the collateral damage would be significant. Under the terms of each proposed bill, the federal Department of Justice, as well as copyright holders, could seek a court order against a Web site that illegally hosts copyrighted content and then wall off the site permanently.
Under the House version, private companies would be allowed to sue Internet service providers for hosting content that they say infringes on copyright. That represents a very big change in the current law as codified in the Digital Millennium Copyright Act, which grants immunity to Web sites as long as they act in good faith to take down infringing content upon notification.
WHY ALL THE ALARM? The bill has exposed a growing fracture between technology and entertainment companies. Digitally oriented companies see SOPA as dangerous and potentially destructive to the open Web and a step toward the kind of intrusive Internet regulation that has made China a global villain to citizens of the Web.
Entertainment companies think that technology companies are aiding and abetting thieves on a broad scale, but the legislation is alarming in its reach, potentially creating a blacklist of sites and taking aim at others for unknowingly hosting a small fraction of copyrighted material. In a joint letter to Congress, Google, Facebook, Twitter, AOL, Yahoo, eBay and many other companies made it clear that they perceived a broader threat in the effort to thwart pirate sites.
“We support the bills’ stated goals — providing additional enforcement tools to combat foreign ‘rogue’ Web sites that are dedicated to copyright infringement or counterfeiting,” the letter read, which was published in a full page ad in The Times.
“Unfortunately, the bills as drafted would expose law-abiding U.S. Internet and technology companies to new uncertain liabilities, private rights of action and technology mandates that would require monitoring of Web sites.”
Laurence H. Tribe, the noted First Amendment lawyer, said in an open letter on the Web that SOPA would “undermine the openness and free exchange of information at the heart of the Internet. And it would violate the First Amendment.”
You can see why big Internet guys are upset by SOPA. Maybe you and I should be, too.
WHY THE POLITICAL SUPPORT? Various amendments intended to tone down SOPA or limit its damage were voted down by large majorities in the House Judiciary Committee in mid-December, an indication that the indignation of various constituencies on the Web is having little impact.
That’s partly because entertainment companies have deep and long-lasting relationships inside the Beltway. Maplight, a site that researches the influence of money in politics, reported that the 32 sponsors of the legislation received four times as much in contributions from the entertainment industry as they did from software and Internet companies.
There is also a cultural divide at work, according to Yancey Strickler, one of the founders of Kickstarter, a Web site that helps raise funds for creative projects, and a critic of SOPA.
“The schism between content creators and platforms like Kickstarter, Tumblr and YouTube is generational,” he wrote in an e-mail. “It’s people who grew up on the Web versus people who still don’t use it. In Washington, they simply don’t see the way that the Web has completely reconfigured society across classes, education and race. The Internet isn’t real to them yet.”
The debate has highlighted how little Congress knows about the Internet they are proposing to re-tool. In a piece often cited on the Web, the computer culture journalist Joshua Kopstein watched the debate in Congress in which members bragged about their online ignorance, and he wrote an open letter on the technology Web site Motherboard titled, “Dear Congress, It’s No Longer O.K. to Not Know How the Internet Works.”
Whether they know what they are doing or not, lawmakers seem intent on moving forward.
Congressional supporters of piracy legislation have been in a big hurry because the Web is starting to come alive with opposition — nearly 90,000 Tumblr users have phoned members of Congress and more than a million people have signed an online petitionprotesting the legislation.
Last week, in a much talked about blog post, Declan McCullagh of CNet speculated thateven though big Web companies like Google, Amazon and Facebook are outgunned in terms of political connections, they have the capability to turn their sites into billboards denouncing SOPA and utilizing their close, constant relationship with consumers.
I like my movies (and music and television) as much as the next couch potato, probably more. And I wouldn’t steal content for any reason, in part because I make a living generating a fair amount of it. But it’s worth remembering that the film industry initially opposed the video cassette recorder and the introduction of DVDs, platforms that became very lucrative businesses for them and remarkable conveniences for the rest of us.
Given both Congress’s and the entertainment industry’s historically wobbly grasp of technology, I don’t think they should be the ones re-engineering the Internet. The rest of us might have to just hold our noses and learn enough about SOPA to school them in why it’s a bad idea.
E-mail: carr@nytimes.com;
Twitter.com/carr2n

This article has been revised to reflect the following correction:
Correction: January 5, 2012
The Media Equation column on Monday, about legislative measures to curb online piracy, misspelled the surname of a founder of the Web site Kickstarter, who commented on the effort. He is Yancey Strickler, not Stickler.

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Four Drugs Cause Most Hospitalizations in Older Adults


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Via: New York Times – November 23, 2011, 5:00 PM

Four Drugs Cause Most Hospitalizations in Older Adults

Some medications may cause some dangerous reactions.Tony Cenicola/The New York TimesSome medications may cause dangerous reactions.
Blood thinners and diabetes drugs cause most emergency hospital visits for drug reactions among people over 65 in the United States, a new study shows.
Just four medications or medication groups — used alone or together — were responsible for two-thirds of emergency hospitalizations among older Americans, according to the report. At the top of the list was warfarin, also known as Coumadin, a blood thinner. It accounted for 33 percent of emergency hospital visits. Insulin injections were next on the list, accounting for 14 percent of emergency visits.
Aspirin, clopidogrel and other antiplatelet drugs that help prevent blood clotting were involved in 13 percent of emergency visits. And just behind them were diabetes drugs taken by mouth, called oral hypoglycemic agents, which were implicated in 11 percent of hospitalizations.
All these drugs are commonly prescribed to older adults, and they can be hard to use correctly. One problem they share is a narrow therapeutic index, meaning the line between an effective dose and a hazardous one is thin. The sheer extent to which they are involved in hospitalizations among older people, though, was not expected, said Dr. Dan Budnitz, an author of the study and director of the Medication Safety Program at the Centers for Disease Control and Prevention.
“We weren’t so surprised at the particular drugs that were involved,” Dr. Budnitz said. “But we were surprised how many of the emergency hospitalizations were due to such a relatively small number of these drugs.”
Every year, about 100,000 people in the United States over age 65 are taken to hospitals for adverse reactions to medications. About two-thirds end up there because of accidental overdoses, or because the amount of medication prescribed for them had a more powerful effect than intended.
As Americans live longer and take more medications — 40 percent of people over 65 take five to nine medications — hospitalizations for accidental overdoses and adverse side effects are likely to increase, experts say.
In the latest study, published in The New England Journal of Medicine, Dr. Budnitz and his colleagues combed through data collected from 2007 to 2009 at 58 hospitals around the country. The hospitals were all participating in a surveillance project run by the C.D.C. that looks at adverse drug events.
A common denominator among the drugs topping the list is that they can be difficult to use. Some require blood testing to adjust their doses, and a small dose can have a powerful effect. Blood sugar can be notoriously hard to control in people with diabetes, for example, and taking a slightly larger dose of insulin than needed can send a person into shock. Warfarin, meanwhile, is the classic example of a drug with a narrow margin between therapeutic and toxic doses, requiring regular blood monitoring, and it can interact with many other drugs and foods.
“These are medicines that are critical,” Dr. Budnitz said, “but because they cause so many of these harms, it’s important that they’re managed appropriately.”
One thing that stood out in the data, the researchers noted, was that none of the four drugs identified as frequent culprits are typically among the types of drugs labeled “high risk” for older adults by major health care groups. The medications that are usually designated high risk or “potentially inappropriate” are commonly used over-the-counter drugs like Benadryl, as well as Demerol and other powerful narcotic painkillers. And yet those drugs accounted for only about 8 percent of emergency hospitalizations among the elderly.
Dr. Budnitz said that the new findings should provide an opportunity to reduce the number of emergency hospitalizations in older adults by focusing on improving the safety of this small group of blood thinners and diabetes medications, rather than by trying to stop the use of drugs typically thought of as risky for this group.
“I think the bottom line for patients is that they should tell all their doctors that they’re on these medications,” he said, “and they should work with their physicians and pharmacies to make sure they get appropriate testing and are taking the appropriate doses.”

Mamografías: más daños que beneficios. Los riesgos de la excesiva prevención


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Con cierta frecuencia los medios de comunicación suelen hablarnos de la bondad de las mamografías para detectar cáncer de mama. Pero esto ha sido cuestionado por la ciencia y una parte de la comunidad médica. Lo último publicado sobre ello es un texto enArchives of Internal Medicine, de H. Gilbert Welch, sobre el escaso-nulo impacto del cribado con mamografía. También lo ha comentado el New York Times: El cribado (screening) del cáncer de mama es absurdo, produce más daños que beneficios.
Especialmente por los medicamentos que se utilizan en los casos de sobre-diagnóstico(más del 40%; es decir, casi la mitad de las mamas extirpadas con cáncer de mamanunca darían metástasis y se sobretratan con cirugía-anestesia, radioterapia y quimioterapia).
“Diversos protocolos y programas recomiendan, en España, que los profesionales insistan en el auto-examen de mamas como medida de aplicación universal para la detección precoz del cáncer de mama; también, que se ofrezca la mamografía a mujeres de menos de 50 años y mayores de 69, especialmente en la práctica privada. ¿Disminuyen estas dos recomendaciones la mortalidad por cáncer de mama? La respuesta es negativa“.
En 2006 volvían a reciordar que el afán de prevenir puede ser peligroso. La prevención del cáncer de mama mediante mamografía es un programa muy popular pero quecarece de fundamento científico y que puede producir más daño que beneficios. Las mujeres deberían tener la información que se propone en este artículo para decidir. Además, como se publica también estos días el 40% del cáncer de mama no necesita quimioterapia.

The New Language of Medicine


Pamela Hartzband, M.D., and Jerome Groopman, M.D.
N Engl J Med 2011; 365:1372-1373October 13, 2011

During our first year of medical school, we spent countless hours learning new words, memorizing vocabulary as if we were studying a foreign language. We discovered that some words that sounded foreign actually represented the familiar: rubeola was measles, pruritus meant itching. Now, we find ourselves learning a new language of medicine filled with words that seem familiar yet feel foreign. Patients are no longer patients, but rather “customers” or “consumers.”1 Doctors and nurses have been transmuted into “providers.” These descriptors have been widely adopted in the media, medical journals, and even on clinical rounds. Yet the terms are not synonymous. The word “patient” comes from patiens, meaning suffering or bearing an affliction. Doctor is derived from docere, meaning to teach, and nurse from nutrire, to nurture. These terms have been used for more than three centuries.
What precipitated the increasing usage of this new vocabulary in medicine? We are in the midst of an economic crisis, and efforts to reform the health care system have centered on controlling spiraling costs. To that end, many economists and policy planners have proposed that patient care should be industrialized and standardized.2 Hospitals and clinics should run like modern factories, and archaic terms such as doctor, nurse, and patient must therefore be replaced with terminology that fits this new order.
The words we use to explain our roles are powerful. They set expectations and shape behavior. This change in the language of medicine has important and deleterious consequences. The relationships between doctors, nurses, or any other medical professionals and the patients they care for are now cast primarily in terms of a commercial transaction. The consumer or customer is the buyer, and the provider is the vendor or seller. To be sure, there is a financial aspect to clinical care. But that is only a small part of a much larger whole, and to people who are sick, it’s the least important part. The words “consumer” and “provider” are reductionist; they ignore the essential psychological, spiritual, and humanistic dimensions of the relationship — the aspects that traditionally made medicine a “calling,” in which altruism overshadowed personal gain. Furthermore, the term “provider” is deliberately and strikingly generic, designating no specific role or type or level of expertise. Each medical professional — doctor, nurse, physical therapist, social worker, and more — has specialized training and skills that are not recognized by the all-purpose term “provider,” which carries no resonance of professionalism. There is no hint of the role of doctor as teacher with special knowledge to help the patient understand the reasons for his or her malady and the possible ways of remedying it, no honoring of the work of the nurse as a nurturer with unique expertise whose close care is essential to healing. Rather, the generic term “provider” suggests that doctors and nurses and all other medical professionals are interchangeable. “Provider” also signals that care is fundamentally a prepackaged commodity on a shelf that is “provided” to the “consumer,” rather than something personalized and dynamic, crafted by skilled professionals and tailored to the individual patient.
Business is geared toward the bottom line: making money. A customer or consumer is guided by “caveat emptor” — “let the buyer beware” — an adversarial injunction and hardly a sentiment that fosters the atmosphere of trust so central to the relationship between doctor or nurse and patient. Reducing medicine to economics makes a mockery of the bond between the healer and the sick. For centuries, doctors who were mercenary were publicly and appropriately castigated, the subjects of caustic characterization in plays by Moliere and stories by Turgenev. Such doctors betrayed their calling. Should we now be celebrating the doctor whose practice, like a successful business, maximizes profits from “customers”?
Beyond introducing new words, the movement toward industrializing and standardizing all of medicine (rather than just safety and emergency protocols) has caused certain terms that were critical to our medical education to all but disappear. “Clinical judgment,” for instance, is a phrase that has fallen into disgrace, replaced by “evidence-based practice,” the practice of medicine based on scientific data. But evidence is not new; throughout our medical education beginning more than three decades ago, we regularly examined the scientific evidence for our clinical practices. On rounds or in clinical conferences, doctors debated the design and results of numerous research studies. But the exercise of clinical judgment, which permitted assessment of those data and the application of study results to an individual patient, was seen as the acme of professional practice. Now some prominent health policy planners and even physicians contend that clinical care should essentially be a matter of following operating manuals containing preset guidelines, like factory blueprints, written by experts.2 These guidelines for care are touted as strictly scientific and objective. In contrast, clinical judgment is cast as subjective, unreliable, and unscientific. But there is a fundamental fallacy in this conception. Whereas data per se may be objective, their application to clinical care by the experts who formulate guidelines is not. This truth, that evidence-based practice codified in clinical guidelines has an inescapable subjective core, is highlighted by the fact that working with the same scientific data, different groups of experts write different guidelines for conditions as common as hypertension and elevated cholesterol levels3 or for the use of screening tests for prostate and breast cancers.4 The specified cutoffs for treatment or no treatment, testing or no testing, the weighing of risk versus benefit — all necessarily reflect the values and preferences of the experts who write the recommendations. And these values and preferences are subjective, not scientific.5
What impact will this new vocabulary have on the next generation of doctors and nurses? Recasting their roles as those of providers who merely implement prefabricated practices diminishes their professionalism. Reconfiguring medicine in economic and industrial terms is unlikely to attract creative and independent thinkers with not only expertise in science and biology but also an authentic focus on humanism and caring.
When we ourselves are ill, we want someone to care about us as people, not as paying customers, and to individualize our treatment according to our values. Despite the lip service paid to “patient-centered care” by the forces promulgating the new language of medicine, their discourse shifts the focus from the good of the individual to the exigencies of the system and its costs. Marketplace and industrial terms may be useful to economists, but this vocabulary should not redefine our profession. “Customer,” “consumer,” and “provider” are words that do not belong in teaching rounds and the clinic. We believe doctors, nurses, and others engaged in care should eschew the use of such terms that demean patient and professional alike and dangerously neglect the essence of medicine.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

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From Beth Israel Deaconess Medical Center and Harvard Medical School — both in Boston.

PSA & New York Times


Healthy men should no longer receive a P.S.A. blood test to screen forprostate cancer because the test does not save lives over all and often leads to more tests and treatments that needlessly cause pain,impotence and incontinence in many, a key government health panel has decided.

Well

Tara Parker-Pope answers some of the most common questions about P.S.A. testing and what the task force recommendations mean for men.

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The draft recommendation, by the United States Preventive Services Task Force and due for official release next week, is based on the results of five well-controlled clinical trials and could substantially change the care given to men 50 and older. There are 44 million such men in the United States, and 33 million of them have already had a P.S.A. test — sometimes without their knowledge — during routine physicals.

The task force’s recommendations are followed by most medical groups. Two years ago the task force recommended that women in their 40s should no longer get routine mammogramssetting off a firestorm of controversy. The recommendation to avoid the P.S.A. test is even more forceful and applies to healthy men of all ages.
“Unfortunately, the evidence now shows that this test does not save men’s lives,” said Dr. Virginia Moyer, a professor of pediatrics at Baylor College of Medicine and chairwoman of the task force. “This test cannot tell the difference between cancers that will and will not affect a man during his natural lifetime. We need to find one that does.”
But advocates for those with prostate cancer promised to fight the recommendation. Baseball’s Joe Torre, the financier Michael Milken and Rudolph W. Giuliani, the former New York City mayor, are among tens of thousands of men who believe a P.S.A. test saved their lives.
The task force can also expect resistance from some drug makers and doctors. Treating men with high P.S.A. levels has become a lucrative business. Some in Congress have criticized previous decisions by the task force as akin to rationing, although the task force does not consider cost in its recommendations.
“We’re disappointed,” said Thomas Kirk, of Us TOO, the nation’s largest advocacy group for prostate cancer survivors. “The bottom line is that this is the best test we have, and the answer can’t be, ‘Don’t get tested.’ ”
But that is exactly what the task force is recommending. There is no evidence that a digital rectal exam or ultrasound are effective, either. “There are no reliable signs or symptoms of prostate cancer,” said Dr. Timothy J. Wilt, a member of the task force and a professor of medicine at the University of Minnesota. Frequency and urgency of urinating are poor indicators of disease, since the cause is often benign.
The P.S.A. test, routinely given to men 50 and older, measures a protein — prostate-specific antigen — that is released by prostate cells, and there is little doubt that it helps identify the presence of cancerous cells in the prostate. But a vast majority of men with such cells never suffer ill effects because their cancer is usually slow-growing. Even for men who do have fast-growing cancer, the P.S.A. test may not save them since there is no proven benefit to earlier treatment of such invasive disease.
As the P.S.A. test has grown in popularity, the devastating consequences of the biopsies and treatments that often flow from the test have become increasingly apparent. From 1986 through 2005, one million men received surgery, radiation therapy or both who would not have been treated without a P.S.A. test, according to the task force. Among them, at least 5,000 died soon after surgery and 10,000 to 70,000 suffered serious complications. Half had persistent blood in their semen, and 200,000 to 300,000 suffered impotence, incontinence or both. As a result of these complications, the man who developed the test, Dr. Richard J. Ablin, has called its widespread use a “public health disaster.”
One in six men in the United States will eventually be found to have prostate cancer, making it the second most common form of cancer in men after skin cancer. An estimated 32,050 men died of prostate cancer last year and 217,730 men received the diagnosis. The disease is rare before age 50, and most deaths occur after age 75.
Not knowing what is going on with one’s prostate may be the best course, since few men live happily with the knowledge that one of their organs is cancerous. Autopsy studies show that a third of men ages 40 to 60 have prostate cancer, a share that grows to three-fourths after age 85.
P.S.A. testing is most common in men over 70, and it is in that group that it is the most dangerous since such men usually have cancerous prostate cells but benefit the least from surgery and radiation. Some doctors treat patients who have high P.S.A. levels with drugs that block male hormones, although there is no convincing evidence that these drugs are helpful in localized prostate cancer and they often result in impotence, breast enlargement and hot flashes.
Of the trials conducted to assess the value of P.S.A. testing, the two largest were conducted in Europe and the United States. Both “demonstrate that if any benefit does exist, it is very small after 10 years,” according to the task force’s draft recommendation statement.
The European trial had 182,000 men from seven countries who either got P.S.A. testing or did not. When measured across all of the men in the study, P.S.A. testing did not cut death rates in nine years of follow-up. But in men ages 55 to 69, there was a very slight improvement in mortality. The American trial, with 76,693 men, found that P.S.A. testing did not cut death rates after 10 years.
Dr. Eric Klein of the Cleveland Clinic, an expert in prostate cancer, said he disagreed with the task force’s recommendations. Citing the European trial, he said “I think there’s a substantial amount of evidence from randomized clinical trials that show that among younger men, under 65, screening saves lives.”
The task force’s recommendations apply only to healthy men without symptoms. The group did not consider whether the test is appropriate in men who already have suspicious symptoms or those who have already been treated for the disease. The recommendations will be open to public comment next week before they are finalized.
Recommendations of the task force often determine whether federal health programs likeMedicare and private health plans envisioned under the health reform law pay fully for a test. But legislation already requires Medicare to pay for P.S.A. testing no matter what the task force recommends.
Still, the recommendations will most likely be greeted with trepidation by the Obama administration, which has faced charges from Republicans that it supports rationing of health care services, which have been politically effective, regardless of the facts.
After the task force’s recommendation against routine mammograms for women under 50, Health and Human Services Secretary Kathleen Sibelius announced that the government would continue to pay for the test for women in their 40s. On Thursday, the administration announced with great fanfare that as a result of the health reform law, more people with Medicare were getting free preventive services like mammograms.
Dr. Michael Rawlins, chairman of the National Institute for Health and Clinical Excellence in Britain, said he was given a P.S.A. test several years ago without his knowledge. He then had a biopsy, which turned out to be negative. But if cancer had been detected, he would have faced an awful choice, he said: “Would I want to have it removed, or would I have gone for watchful waiting with all the anxieties of that?” He said he no longer gets the test.
But Dan Zenka, a spokesman for the Prostate Cancer Foundation, said a high P.S.A. test result eventually led him to have his prostate removed, a procedure that led to the discovery that cancer had spread to his lymph nodes. His organization supports widespread P.S.A. testing. “I can tell you it saved my life,” he said.

Evacuation in New York City


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Mass Transit to Shut Saturday at Noon

New York City officials warned residents of low-lying areas on Friday that Hurricane Irene was such a threat that people simply had to get out.

N.Y. Hurricane Evacuation Zones

Parts of the city under mandatory evacuation orders.

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To Our Readers

During this emergency, The New York Times is providing unlimited free access to storm coverage on nytimes.com and its mobile apps.
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