Long-Term Survival and Quality of Life Justify Cardiac Surgery in the Very Elderly Patient

Long-Term Survival and Quality of Life Justify Cardiac Surgery in the Very Elderly Patient

Ravi K. Ghanta, MD, Prem S. Shekar, MD, Siobhan McGurk, BS, Donna M. Rosborough, RN, MS, and Sary F. Aranki, MD Division of Cardiac Surgery, Brigham a...

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Ravi K. Ghanta, MD, Prem S. Shekar, MD, Siobhan McGurk, BS, Donna M. Rosborough, RN, MS, and Sary F. Aranki, MD Division of Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts

Background. Elderly patients are often discouraged from undergoing cardiac surgery procedures owing to the perception of high mortality and poor functional outcomes. This study evaluates long-term survival and quality of life after cardiac surgery in octogenarian and nonagenarian patients. Methods. We identified a 459 patient cohort greater than 80 years of age who underwent elective cardiac surgery at our institution from 1994 to 1999. Survival was assessed with Kaplan-Meier analysis and compared with an age-matched and sex-matched population cohort. Among survivors, quality of life was assessed 8 years postoperatively using the Medical Outcomes Study Short Form 12 Health Survey, version 2. Risk factors for mortality were identified with Cox regression. Results. Operative mortality was 4.1%. Actuarial postoperative 5-year and 10-year survival was 53% and 27%,

respectively. When compared with age- and sex-matched general population data, relative survival (excluding operative deaths) was 90.4% at 5 years and 78.7% at 10 years. Risk factors for late mortality included age greater than 85, male sex, low body mass index, renal failure, and postoperative respiratory failure. Survivors’ median quality of life mental health score was higher (55.2 versus 48.9; p < 0.05) and physical health score was equivalent (39.3 versus 39.8; p ⴝ 0.66) to the general elderly population. Conclusions. Cardiac surgery in the very elderly patient can be performed with low operative mortality, excellent long-term survival, and postoperative quality of life exceeding that of the general elderly population.

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cardiac surgery in a large cohort of octogenarian and nonagenarian patients. We also identify risk factors for early and late mortality and evaluate the utility of existing clinical predictive algorithms to aid in patient selection.

lthough cardiac surgery among octogenarian and nonagenarian patients is becoming increasingly common, decisions regarding surgery in this very elderly population remain difficult. As the elderly represent the fastest growing population demographic in industrialized nations, this challenge will certainly increase [1, 2]. Numerous clinical studies have demonstrated favorable operative morbidity and mortality in very elderly patients [3– 6]. Several studies have also demonstrated that postoperative life expectancy can approach and even exceed that of the general elderly population [7–9]. Despite these results, elderly patients are still only hesitantly referred for cardiac surgery evaluation [10 –13]. To many patients and physicians, quality of life (QoL) is more important than survivorship alone. The question has now shifted from whether the very elderly can undergo surgery to whether they should undergo surgery [14, 15]. To justify cardiac surgery in this patient population, both favorable long-term survival and QoL measures must be achieved. Few studies have evaluated long-term survival and QoL after cardiac surgery in the elderly, and thus minimal data exist to guide clinical decisions for this patient population. This study evaluates long-term survival and QoL after

Accepted for publication April 22, 2011. Address correspondence to Dr Aranki, Division of Cardiac Surgery, Brigham and Women’s Hospital, 15 Francis St, Boston, MA 02115; e-mail: [email protected]

© 2011 by The Society of Thoracic Surgeons Published by Elsevier Inc

(Ann Thorac Surg 2011;92:851–7) © 2011 by The Society of Thoracic Surgeons

Patients and Methods Patients All patients 80 years of age or older who underwent elective cardiac surgery between January 1994 and December 1999 at Brigham and Women’s Hospital were identified. Patients were stratified into three groups according to operation: coronary artery bypass graft (CABG), valve surgery, and valve surgery with CABG. Patient preoperative, operative, and postoperative variables were retrieved from the prospective Brigham Cardiac Surgery Database. This study was approved by the Institutional Review Board at Brigham and Women’s Hospital.

Outcomes The primary outcome measures of this study were frequency of postoperative complications, long-term survival, and long-term QoL. In all patients, the postoperative course was followed and intubation time, intensive care unit and hospital length of stay, and patient disposition were determined. Postoperative complications included myocardial infarction, cerebrovascular accident (CVA), respiratory failure, atrial fibrillation, renal failure, and reoperation for 0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.04.083

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well-validated method to quantify QoL in eight domains of physical, social, and mental functioning with two summary measures—physical component score (PCS) and mental component score (MCS) [16, 17].

bleeding. Postoperative myocardial infarction was defined as the presence of at least two of the following: prolonged typical chest pain not relieved by nitrates, enzyme level elevation, new wall motion abnormalities, or ST-segment or Q-wave electrocardiographic changes in two or more contiguous leads. Cerebrovascular accident included strokes, transient ischemic attacks, and coma. Respiratory failure was defined as prolonged intubation greater than 24 hours secondary to pulmonary edema, adult respiratory distress syndrome, or pneumonia. Similarly, renal failure was defined as development of a creatinine greater than 2.0 mg/dL or twice the baseline level. Operative mortality was defined as death within 30 days of surgery or at any point while still in hospital. Midterm survival and long-term survival was defined as 5-year and 10-year survival, respectively. Long-term survival was determined from medical records, a query of the Social Security Death Index, or communication with the patient’s family or physician as of June 2008. The QoL was determined in the 148 survivors with the selfadministered Medical Outcomes Study Short Form 12 (SF-12) Health Survey, version 2 [16]. Nonresponders were further queried with a telephone interview. Of the 158 survivors, 114 (72%) returned SF-12 surveys, with a median follow-up time of 7.9 years. The SF-12 survey is a

Analysis and Statistical Methods Statistics were performed using SPSS 13.0 (SPSS, Chicago, IL), and a p value less than 0.05 was considered statistically significant. Evaluation of dichotomous variables was done with Fisher’s exact test. One-way analyses of variance and Mann-Whitney U tests were used to evaluate normally and nonnormally distributed continuous variables. Responder bias was evaluated by comparing the characteristics and in-hospital outcomes of subjects alive at the time of the questionnaire administration to those of the cohort who did not survive, as well as comparing characteristics and in-hospital outcomes between surviving subjects participating and those who did not. Survival curves were calculated using the KaplanMeier method [18]. Observed postoperative survival was compared with predicted survival of an age-matched and sex-matched cohort from United States census data [19]. Risk factors for late mortality were examined in both univariate and multivariable Cox regression analyses. For the latter, nonnormal variables were evaluated both

Table 1. Patient Preoperative and Surgical Characteristics Overall Characteristics

No.

Number of patients Age, median (range) Female NYHA class III or IV Hypertension Diabetes mellitus Renal failure CVA Atrial fibrillation Body mass index, median (IQR) LVEF, median (IQR) Previous cardiac surgery Procedures No. proximal anastomoses No. distal anastomoses Aortic valve Mitral valve Aortic and mitral valve Bypass time, median minutes (IQR) Cross-clamp time, median minutes (IQR) Mean EuroSCORE (SD) Mean STS score (SD)

459

CABG %

%

268

82 (80–94) 223 48.6 192 41.8 320 69.7 124 27.0 55 12.0 139 30.3 62 13.5 24.3 (22–27)

52

No.

55 (40–60) 11.3

58.4 82 (80–93) 134 50.0 117 43.7 180 67.2 74 27.6 28 10.4 77 28.7 36 13.4 24.2 (24–27)

28

CABG ⫹ Valve

Valve

54 (40–60) 10.4

No.

%

91

19.8 82 (80–93) 44 48.4 30 33.0 69 75.8 26 28.6 13 14.3 34 37.4 8 8.9 24.5 (22–27)

No. 72

15.7 82 (80–94) 33 45.8 33 45.8 49 68.1 18 25.6 11 15.3 19 26.4 12 16.7 24.4 (23–28)

55 (44–60) 9

9.9

%

13

50 (40–61) 18.1

2 (1–3)



1 (1–3)

101 (79–129)

3 (1–5) — — — 100 (76–138)

— 30 (33.0) 36 (39.6) 17 (18.7) 107 (80–140)

2 (1–3) 35 (48.6) 27 (37.5) 7 (9.7) 100 (80–143)

71 (51–94)

70 (54–96)

75 (52–93)

72 (55–91)

0.16 (0.12) 0.24 (0.15)

0.15 (0.12) 0.24 (0.14)

0.17 (0.14) 0.22 (0.14)

0.17 (0.13) 0.24 (0.17)

CABG ⫽ coronary artery bypass graft; CVA ⫽ cerebrovascular accident; EuroSCORE ⫽ European System for Cardiac Operative Risk Evaluation; IQR ⫽ interquartile range; LVEF ⫽ left ventricular ejection fraction; NYHA ⫽ New York Heart Association; STS ⫽ The Society of Thoracic Surgeons.

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fibrillation (44%) followed by respiratory failure (17%), reoperation for bleeding (7%), CVA (7%), and renal failure (2%). The median hospital length of stay was 8 days, with 28% of patients discharged to home and 68% of patients discharged to a rehabilitation facility. There was no significant difference in morbidity or mortality between the different surgical subgroups.

as ordinals and as continuous variables. To evaluate the utility of existing clinical risk estimation tools, the predicted operative mortality was calculated utilizing The Society of Thoracic Surgery (STS) and the logistic European System for Cardiac Operative Risk Assessment (EuroSCORE) algorithms [20, 21]. The STS and EuroSCORE predicted operative mortality were then compared with the observed operative mortality. Receiveroperating characteristic curves were determined, and the area under the receiver-operating characteristic curve (AUROC) was used to assess the accuracy of the score in predicting mortality [22]. The QoL data were compared with population data for persons aged 75 years or older in the United States [16].

Long-Term Survival Kaplan-Meier survival curves are presented in Figures 1 and 2. Figure 1 demonstrates survival for all patients and comparison with age-adjusted population data. Overall survival was 53% and 27% at 5 and 10 years, respectively. In comparison, age-matched and sex-matched population survival was 62% and 35% at 5 and 10 years, respectively. Figure 2 demonstrates survival in the three procedure groups. There was no significant difference in survival among the three procedure groups.

Results Patient Characteristics Patient preoperative and operative characteristics and comorbidities are summarized in Table 1. The most frequent preoperative comorbidities were hypertension (70%), history of CVA (30%), diabetes mellitus (27%), atrial fibrillation (13%), and renal failure (12%). The most common operation was CABG (58%), followed by valve surgery (20%), and valve surgery with CABG (16%). There were no statistically significant preoperative differences between the different surgical subgroups.

Quality of Life Overall, 114 of 158 survivors (72%) returned SF-12 questionnaires. A responder bias analysis showed that responders were more likely to be male than nonresponders were (55% versus 32%; p ⬍ 0.05). Nonresponders did not differ significantly from responders on age, comorbidity load, procedure mix, and bypass and cross-clamp times. There was no difference in incidences of postoperative complications between the responders and nonresponders. Figure 3 illustrates SF-12 scores in the 8 domains and the summary PCS and MCS scores for the study patients compared with the general elderly population. Survivors’ median QoL mental health score was higher (55.2 versus

Postoperative Complications and Operative Mortality Postoperative course, morbidity, and mortality are summarized in Table 2. Operative mortality was 4.4% overall. The most frequent postoperative complication was atrial

Table 2. Postoperative Course, Morbidity and Mortality Overall Postoperative Course

No.

Number of patients Intubation time, median hours (IQR) ICU LOS, median days (IQR) Hospital LOS, median (IQR) Discharged to home Postoperative complications Atrial fibrillation Respiratory failure Reoperation for bleeding CVA Renal failure Operative mortality Five-year survival Ten-year survival Survival, median years (IQR)

459

CABG %

CABG ⫹ Valve

Valve

No.

%

268

No.

%

91

No.

%

72

15 (10–18)

15 (10–17)

16 (10–21)

15 (12–18)

2 (1–2)

1.5 (1–2)

2 (1–3)

2 (1–2)

8 (6–12)

9 (6–13)

8 (6–10)

7 (5–11)

127

27.7

200 43.6 76 16.6 31 6.8 31 6.8 11 2.4 20 4.4 253 54 78 17 5.4 (1.7-7.4)

CABG ⫽ coronary artery bypass graft surgery; LOS ⫽ length of stay.

72

26.7

23

120 44.8 44 16.4 15 5.6 18 6.6 8 3.0 11 4.1 145 54 40 15 5.5 (1.8–7.2)

37 17 8 7 1 3 50 13

CVA ⫽ cerebrovascular accident;

25 40.7 18.7 8.8 7.2 1.1 3.3 55 14 5.5 (2.7–7.2)

ICU ⫽ intensive care unit;

25

34.3

30 41.7 10 13.9 7 9.7 4 5.6 2 2.8 6 8.3 36 50 14 19 4.9 (1.8–8.1) IQR ⫽ interquartile range;

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Fig 1. Kaplan-Meier survival curve. (BWH ⫽ Brigham and Women’s Hospital [solid line]; US ⫽ United States [broken line]; yo ⫽ years old.)

48.9; p ⬍ 0.05) and physical health score was equivalent (39.3 versus 39.8; p ⫽ 0.66) to that of the general elderly population. There was no significant difference in QoL between the surgical subgroups.

Predictors of Mortality Risk factors from the Cox regression for operative and late mortality are presented in Table 3. For operative mortality, no single preoperative comorbidity significantly increased risk. Operative factors such as performance of aortic surgery (hazard ratio [HR] 4.8) and prolonged bypass time (HR 1.01) did increase risk for operative mortality. The occurrence of a single postoperative complication, other than atrial fibrillation or reop-

Fig 2. Kaplan-Meier survival curve by procedure type: coronary artery bypass graft surgery only (solid line); CABG plus valve (broken line); and valve only (dotted line).

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Fig 3. Short-Form 12 Quality of Life Survey data. (BWH ⫽ Brigham and Women’s Hospital; CABG ⫽ coronary artery bypass graft surgery; US ⫽ United States; yo ⫽ years old.)

eration for bleeding, increased risk for operative mortality. The greatest risk for operative mortality was the development of new-onset renal failure (HR 38), followed by respiratory failure (HR 25). For late mortality, risk factors included age greater than 85 years, male sex, preoperative renal failure, aortic surgery, postoperative renal failure, and postoperative respiratory failure. Higher preoperative body mass index was associated with decreased risk. Figure 4 demonstrates receiver operating characteristic curves for the logistic EuroSCORE and STS score for predicting 30-day mortality. There was no difference between the AUROCs of the logistic EuroSCORE and the STS (0.538 versus 0.635; p ⫽ 0.21).

Comment Cardiac surgery for octogenarian and nonagenarian patients is now a clinical reality; however, long-term functional outcomes remain unclear. To many patients and physicians, QoL is as important a consideration as survivorship alone and is a key factor in the decision to offer or undergo cardiac surgery. The principal finding of this study is that both long-term survival and long-term QoL are favorable after cardiac surgery in octogenarian and nonagenarian patients. In this series, operative mortality was 4.1%. In previous studies, operative mortality has ranged from 5.1% to 10.1% [9]. No single preoperative comorbidity increased risk for operative mortality. Although the factors of hypertension, diabetes, and chronic obstructive pulmonary disease likely contribute to operative mortality, they are so prevalent in this patient population they are not useful predictors [7]. We did find that postoperative renal failure and respiratory failure significantly increase risk for operative mortality. In these very elderly patients, preventive measures to minimize respiratory complications, such as early extubation, head of bed elevation, early ambulation, and aspiration precautions, should be

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Table 3. Risk Factors for Operative and Late Mortality Risk Factors Operative mortality Preoperative factors Age, ⬎85 years Female Hypertension Diabetes mellitus NHYA III or IV Preoperative renal failure COPD Peripheral vascular disease Body mass index Previous cardiac surgery Previous myocardial infarction Aorta surgery, yes/no Valve surgery, yes/no Postoperative factors Bypass time, minutes Atrial fibrillation Myocardial infarction CVA Renal failure Respiratory failure Reoperation for bleed Late mortality Age, ⬎85 years Female Body mass index Preoperative renal failure Aorta surgery Postoperative renal failure Postoperative respiratory failure COPD ⫽ chronic obstructive pulmonary disorder;

No. of Patients

Hazard Ratio

Confidence Intervals

111 223 320 124 192 55 147 150 448 20 194 29 163

0.99 0.86 0.64 0.434 1.74 1.20 1.15 0.68 0.97 2.04 0.72 4.77 1.61

0.844–1.153 0.35–2.12 0.25–1.6 0.18–1.07 0.71–4.29 0.26–5.5 0.45–2.95 0.24–1.9 0.87–1.087 0.65–6.34 0.29–1.77 1.21–18.83 0.55–4.71

456 200 14 31 11 76 31

1.01 0.69 6.86 12.06 38.15 25.27 2.59

111 223 448 55 29 11 76

1.06 0.68 0.97 2.04 1.64 4.22 3.11

CVA ⫽ cerebrovascular accident;

aggressively employed. In addition, nephrotoxic drugs and overdiuresis should be minimized, and renal function should be closely monitored. We also found that higher preoperative body mass index was associated with a reduced risk for mortality. Nutrition preoperatively and postoperatively should be emphasized. Similar to the findings of previous studies, this study demonstrates favorable midterm and long-term survival after cardiac surgery. In this series, 5-year and 10-year survival was 53% and 27%, respectively. In comparison, 5-year and 10-year age-matched and sex-matched population survival was 62% and 35%, respectively. We found no significant difference in survival when compared with an age- and sex-matched US population. In this patient population, relative survival, defined as the ratio of observed to expected survival, rather than absolute survival is a more useful mortality measure. When compared with age-matched general population data, relative survival (excluding operative deaths) was 90.4% at 5 years and 78.7% at 10 years. Krane and colleagues [9] found that 5-year and 10-year survival after cardiac

p Value

0.87 0.74 0.34 0.07 0.23 0.82 0.77 0.46 0.54 0.22 0.48 0.03 0.39

1.00–1.01 0.27–1.75 1.33–35.37 4.49–32.39 10.85–148.63 8.17–78.14 0.72–9.37

0.03 0.43 0.02 ⬍0.01 ⬍0.01 ⬍0.01 0.15

1.01–1.11 0.54–0.86 0.94–0.99 1.49–2.80 1.01–2.66 2.14–8.32 2.335–4.17

0.01 ⬍0.01 0.02 ⬍0.01 0.04 ⬍0.01 ⬍0.01

NYHA ⫽ New York Heart Association.

surgery was 60% and 23%, respectively, for 1,003 German patients greater than 80 years of age. They also found no difference when compared with age-matched and sexmatched German population data. Stoical and colleagues [7] found that 5-year survival was 82.1% in a series of 706 octogenarian patients from the United Kingdom after cardiac surgery. In addition, these patients outlived their peers when compared with an age-matched and sexmatched cohort at 5 years. Likes and colleagues [8] reported 54.7% 5-year survival and 27.1% 10-year survival after aortic valve replacement for 419 octogenarian patients. In a series of 49 nonagenarians, Ellery and colleagues [6] reported a 3-year survival of 67% after cardiac surgery. Special and colleagues [5] reported a 5-year survival of 52% after cardiac surgery for 127 nonagenarians. We found that age greater than 85, male sex, low body mass index, preoperative or postoperative renal failure, postoperative respiratory failure, or undergoing aortic surgery increased risk for late mortality. Previous studies have also found renal and respiratory insufficiency to be

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Fig 4. Receiver operating characteristic (ROC) curve of the European System for Cardiac Operative Risk Evaluation (EuroSCORE) and The Society of Thoracic Surgeons (STS) score for predicting operative mortality. The C-statistic for EuroSCORE (blue line) and the STS score (red line) was 0.63 and 0.54, respectively.

a risk factors for late mortality [9, 23, 24]. Krane and colleagues [9] also noted atrial fibrillation to increase risk, with a hazard ratio of 1.48. In this study, however, we did not find that atrial fibrillation increased risk for operative or late mortality. Few previous studies have focused on postoperative QoL. Fruitman and colleagues [23] surveyed 99 octogenarian patients 15.7 months postoperatively using the Short Form-36 and Seattle Angina Questionnaires. They found that survey scores were equivalent to those of the general elderly population, with 84% of patients living independently and 75% rating their health as good or excellent. Chaturvedi and colleagues [25] conducted a prospective study to evaluate living arrangements and participation in leisure activities of 300 octogenarians. At 3.5 years postoperatively, 72% lived at home and 98% remained involved in social and cognitive leisure activities. Ullery and colleagues [6] surveyed 23 nonagenarians 4 years postoperatively with SF-12; they found that SF-12 scores were similar to those of the general elderly population. Using Short Form-36, Krane and colleagues [9] surveyed 386 German patients over age 80 3.6 years postoperatively and found that postoperative patients had improved PCS (38.2 versus 35.4; p ⬍ 0.002) and equivalent MCS (48.1 versus 40.5; p ⫽ 0.1) scores compared with a reference elderly population. In this study, we found that 114 octogenarian and nonagenarian patients 8 years postoperatively report

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higher MCS scores and similar PCS scores compared with those of the general elderly population. The MCS score is a summary score taking into account mental and social functioning. This finding is important, as impaired cognitive functioning is a frequently cited concern after cardiac surgery, especially in the elderly [26]. Despite undergoing an invasive operation, the PCS score is equivalent to that of the general elderly population, indicating that patients recover to a normal physical functioning status. As with all surgical procedures, appropriate patient selection is critical. At our institution, there were no universal selection criteria for cardiac surgery in elderly patients. The decision to offer surgery was a case-specific decision. Based on the results of this study and others, patients with renal insufficiency, respiratory insufficiency, and low body mass index are at a higher risk for postoperative morbidity and mortality and should be carefully considered for surgery. In these patients, less invasive options such as transcatheter procedures may be more attractive. At present, the most widely used risk estimation systems are the STS and EuroSCORE. The AUROC is a well-established measure of diagnostic performance of a test. In this series using the AUROC, neither measure reliably predicted operative mortality [27]. This finding confirms previous findings that these existing risk models are limited in the elderly population [21, 28]. Emerging indices such as frailty index and gait assessment may prove to be more useful to evaluate risk for cardiac surgery in the elderly [29]. As a single-institution observational cohort study, our study has some important limitations. Our patient selection may differ from other environments and may not be generalizable to all elderly patient cohorts. Full determination of risks and benefits of surgery requires comparison of operative patients with nonoperative patients. We believe this comparison is best done with a prospective study. As our clinical database only captures operative patients, there was no suitable nonoperative cohort for comparison. The QoL data are subject to a responder bias. Poorly functioning survivors might not have returned the questionnaire. A responder bias analysis, however, did not reveal any significant differences in preoperative characteristics or in-hospital outcomes between responders and nonresponders. However, true postoperative QoL might be lower than reported. In this study, we focused on elective cardiac surgery and excluded urgent and emergent cases; clinical decision making differs significantly between the elective versus nonelective scenario. In the elective scenario, full consideration of all options can be performed, whereas in the nonelective scenario, choices are often more limited. It is well known that nonelective surgery for all age groups is associated with poorer outcomes. These outcome data, however, are not relevant to consideration of elective surgery. We recently presented our outcomes for nonelective cardiac surgery, demonstrating an operative mortality of 11% and median survival of 5.2 years [30]. Operative mortality was higher for nonelective surgery; however, there was no

statistically significant difference in median long-term survival. In conclusion, octogenarian and nonagenarian patients can obtain favorable survival and QoL after cardiac surgery. Long-term survival and QoL are equivalent to the general population. Elderly patients with renal insufficiency or failure and risks for postoperative respiratory failure have increased risks for mortality and should be carefully counseled before offering surgery. Existing clinical risk assessment algorithms overestimate risk and should be carefully considered before they are used as contraindications for surgical intervention. This study was supported by funding from the Department of Surgery at Brigham and Women’s Hospital.

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