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Fusiform Gyrus Volume Reduction in First-Episode Schizophrenia
A Magnetic Resonance Imaging Study
Chang Uk Lee, MD, PhD;
Martha E. Shenton, PhD;
Dean F. Salisbury, PhD;
Kiyoto Kasai, MD;
Toshiaki Onitsuka, MD, PhD;
Chandlee C. Dickey, MD;
Deborah Yurgelun-Todd, PhD;
Ron Kikinis, MD;
Ferenc A. Jolesz, MD;
Robert W. McCarley, MD
Arch Gen Psychiatry. 2002;59:775-781.
ABSTRACT
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Background The fusiform gyrus (occipitotemporal gyrus) is thought to be critical
for face recognition and may possibly be associated with impaired facial recognition
and interpretation of facial expression in schizophrenia. of postmortem studies
have suggested that fusiform gyrus volume is reduced in schizophrenia, but
there have been no in vivo structural studies of the fusiform gyrus in schizophrenia
using magnetic resonance imaging.
Methods High–spatial resolution magnetic resonance images were used to
measure the gray matter volume of the fusiform gyrus in 22 patients with first-episode
schizophrenia (first hospitalization), 20 with first-episode affective psychosis
(mainly manic), and 24 control subjects.
Results Patients with first-episode schizophrenia had overall smaller relative
volumes (absolute volume/intracranial contents) of fusiform gyrus gray matter
compared with controls (9%) and patients with affective psychosis (7%). For
the left fusiform gyrus, patients with schizophrenia showed an 11% reduction
compared with controls and patients with affective psychosis. Right fusiform
gyrus volume differed in patients with schizophrenia only compared with controls
(8%).
Conclusion Schizophrenia is associated with a bilateral reduction in fusiform gyrus
gray matter volume that is evident at the time of first hospitalization and
is different from the presentation of affective psychosis.
INTRODUCTION
THE FUSIFORM GYRUS (FG), or occipitotemporal gyrus, is located on the
ventromedial surface of the temporal and occipital lobes. Recently, this gyrus
received attention because of its critical role in face recognition.1-3 Evidence from functional
neuroimaging and neuropsychological studies4-5
suggests that there are specific mechanisms for face perception in the FG
in humans that are distinct from the mechanisms for perception of other objects.
Using functional magnetic resonance imaging (fMRI), Kanwisher et al6 found that the FG was selectively involved in the
perception of faces. These findings excluded alternative accounts of the function
of the FG in face perception, such as visual attention or general processing
of any animate or human forms. Moreover, the necessary role of the FG in face
recognition has been supported by findings from neuropsychological and anatomical
studies7-8 of patients who have
selectively lost the ability to recognize faces (prosopagnosia).
There is also accumulating evidence9-11
to suggest that patients with schizophrenia may have a deficit in face processing.
Impaired processing of faces in patients with schizophrenia may also underlie
some aspects of their disturbance in social skills, as interpersonal interactions
largely depend on facial recognition12 and
interpretation of facial expressions.13-14
Yet another line of evidence for impaired facial recognition in schizophrenia
is that abnormal facial perception may be related to symptoms of delusional
misinterpretation, a disturbance sometimes observed in patients with schizophrenia.15-16 For example, Hudson and Grace17 reported that a case of misidentification syndrome
was associated with a region anterior to the typical face area, in the mid
FG. These findings, taken together, suggest that the FG might be one of the
brain areas underlying some of the pathophysiology of schizophrenia.
Despite evidence for FG abnormalities in schizophrenia, we know of only
one research group18-19 that has
measured FG volume in a postmortem study of schizophrenia. These investigators
reported reduced left FG volume and a reversal of the normal left>right volume
asymmetry in patients with schizophrenia. However, to our knowledge, there
have been no structural MRI studies examining FG volume change in schizophrenia.
In part, this may be due to difficulties in accurately identifying FG boundaries
because of neuroanatomical variations. The FG is bordered medially by the
collateral sulcus and laterally by the occipitotemporal sulcus, both of which
are frequently interrupted, with bifurcations particularly in the anterior
and posterior part of the FG.20-21
Another potential impediment to defining FG boundaries is MRI susceptibility
artifact at the interface between the brain and petrous bones, often encountered
in the ventral area of the temporal lobe.22
These neuroanatomical ambiguities and artifacts make it difficult to identify
FG landmarks using MRI slices in a single plane.
Thus, in the present study, we use 3-dimensional information to provide
reliable measures of FG gray matter volume in patients with first-episode
schizophrenia, patients with first-episode affective psychosis, and control
subjects. Although structural MRI data demonstrate abnormal brain structures
in schizophrenia,23-25
it is important to evaluate patients at the first episode as the effects of
chronicity of illness and long-term treatment may confound structural MRI
findings in patients with chronic schizophrenia. Examining patients with first-episode
schizophrenia and patients with first-episode affective psychosis is also
important to investigating whether changes in brain structure are specific
to schizophrenia or are part of a more general pathological process of psychosis.
In addition, addressing this issue is important because it will help answer
the question of whether the psychosis associated with affective disorder and
that associated with schizophrenia represent different disorders or variants
of a single disorder of psychosis that has somewhat different expressions.26 Hirayasu et al27-28
previously reported that patients with first-episode schizophrenia were different
from patients with first-episode affective psychosis in evincing smaller gray
matter volume in the posterior superior temporal gyrus, planum temporale,
and Heschl's gyrus.
PARTICIPANTS AND METHODS
PARTICIPANTS
Twenty-four controls (21 men and 3 women), 22 patients with first-episode
schizophrenia (17 men and 5 women), and 20 patients with first-episode affective
psychosis (15 men and 5 women) participated in this study. Patients were recruited
from inpatients at McLean Hospital, a psychiatric hospital affiliated with
Harvard Medical School. Control subjects were recruited through newspaper
advertisements. After a complete description of the study, written informed
consent was obtained from all participants.
Patients and control subjects met inclusion criteria for age (18-55
years); IQ greater than 75; right-handedness29;
and a negative history of seizures, head trauma with loss of consciousness,
or neurologic disorder and no lifetime history of alcohol or other drug dependence.
Control subjects also had no Axis I psychiatric disorders or a first-degree
relative with Axis I psychiatric disorders (determined by Structured Clinical
Interview for DSM-III-R, Non-Patient-Edition,30 and Structured Clinical Interview for DSM-III-R, Personality Disorder31).
Demographic data for each group are presented in Table 1.
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Table 1. Demographic and Clinical Characteristics of the 3 Study Groups*
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Patients were diagnosed based on the Structured Clinical Interview for DSM-III-R32 and by a review
of hospital course and medical records. The affective psychosis group included
16 patients with bipolar (manic) disorder and 4 with major depressive (unipolar)
disorder. The statistically significant results reported in the "Results"
section remained the same with exclusion of the 4 major depressive patients.
All patients manifested psychosis. Diagnoses were confirmed at a 1-year follow-up
interview. First episode was operationally defined as the first psychiatric
hospitalization, as in previous studies.27-28
Age at time of first medication (Table 1) provided both a measure of duration of medication administration
and a relatively objective estimate of symptom onset (most dates were from
hospital records). Current chlorpromazine-equivalent medication dosage and
duration of administration before MRI were based primarily on hospital records,
with patient information also used; the median duration of psychotropic medication
administration before MRI was short (Table
1). Participants in this study included 15 new individuals and 51
common to an earlier study of the planum temporale and Heschl's gyrus.28
CLINICAL EVALUATIONS
The Brief Psychiatric Rating Scale33
was administered to all patients. General level of functioning was evaluated
using the Global Assessment Scale.34 The Mini-Mental
State Examination35 was used to rule out dementia
or delirium. In addition, the information subscale of the Wechsler Adult Intelligence Scale–Revised36
was used to estimate general fund of information, and the digits-forward and
digits-backward subscales of the Wechsler Adult Intelligence
Scale–Revised were used to evaluate immediate and short-term
memory, attention, and concentration. Socioeconomic status (SES) and parental
SES were assessed using the Hollingshead 2-factor scale.37
All of these assessments were conducted by one of two psychologists (M.E.S.
and D.F.S.).
MRI ACQUISITION AND PROCESSING
Magnetic resonance images were acquired with a 1.5-T scanner (GE Medical
Systems, Milwaukee, Wis). The scanning and image methods are described in
detail elsewhere.38-40
Briefly, the acquisition protocol included 2 MRI pulse sequences. The first
sequence was a coronal series of contiguous spoiled gradient-recalled acquisition
(SPGR) images (repetition time, 35 milliseconds; echo time, 5 milliseconds;
1 repetition; 45° mutation angle; 24-cm field of view; number of excitations,
1.0; and matrix, 256 x 256 [192 phase-encoding steps] x 124). Voxel
(volume of pixel) dimensions were 0.9375 x 0.9375 x 1.5 mm. Data
were formatted in the coronal plane and analyzed as 124 coronal, 1.5-mm-thick
slices. This protocol was used for measuring the FG because the coronal plane
offers excellent visualization of the FG. The second acquisition sequence
resulted in an axial series of contiguous double-echo (proton-density and
T2-weighted) images (repetition time, 3000 milliseconds; echo time, 30 and
80 milliseconds; 24-cm field of view; and interleaved acquisition with 3-mm
slice thickness). Voxel dimensions were 0.9375 x 0.9375 x 3.0
mm. The latter pulse sequence was used to evaluate total intracranial content
(ICC). An anisotropic diffusion filter (k = 13 for SPGR and 90 for proton-density
and T2-weighted images; iteration, 3)38 was
applied to the images to reduce noise before processing each set of scans.
The intensity information from the SPGR and T2-weighted images was then used
in a fully automated segmentation program to classify tissue into gray matter,
white matter, and cerebrospinal fluid. An iterative expectation maximization
algorithm was used initially to estimate image intensity inhomogeneities,
apply intensity corrections based on these estimates, and then classify tissue
based on the same set of signal intensity parameters for all participants
(ie, one segmentation map was used for all cases).40
As in previous studies,28 images were aligned
using the line between the anterior and posterior commissures and the sagittal
sulcus to correct head tilt, and they were also resampled to make voxels isotropic
(sides measured 0.9375 mm). Segmented voxels were used to assist in the manual
definition of the regions of interest (ROIs).
DEFINITION OF THE FG
The FG is a spindle-shaped structure that is coextensive with the length
of the temporal lobe at a distance lateral to the parahippocampal gyrus.41 Anatomically, the collateral sulcus forms the medial
border of the FG along its entire length. The occipitotemporal sulcus forms
the lateral border of the FG along its entire length. In some anatomical definitions,
the anterior and posterior transverse collateral sulci are used to define
the anterior and posterior FG boundaries.20-21
However, the anterior and posterior borders are often hard to identify reliably
on MRIs, and, consequently, different landmarks have to be used for the segmentation
of this structure.
In the present study, we used criteria similar to that of Kim et al,42 who provided detailed guidelines for FG measurement
in the parcellation of the temporal lobe. Drawing for the FG was performed
on the coronal plane. It was essential to refer to axial and sagittal orientations
for cases in which the borders were ambiguous on coronal slices. The anterior
landmark was reliably defined by one slice posterior to the appearance of
the mamillary body. The posterior landmark was determined by the anterior
tip of the parieto-occipital sulcus in the midsagittal plane. These landmarks
were chosen because they were the most reliable for delineating the FG, although
small amounts of the anterior and posterior parts of the FG were excluded.
This approach prevented erroneous inclusion of parts of another structure
in FG measurement. The collateral and occipitotemporal sulci were used to
determine the medial and lateral FG borders, respectively. In some cases,
these sulci were interrupted or duplicated, particularly in the posterior
part near the preoccipital incisura. In these sections, the more laterally
located sulcus was used as the border. Figure
1 shows the FG ROI on a 3-dimensional reconstruction of the ventral
surface of the brain and on a coronal slice.
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Figure 1. The fusiform gyrus region of interest
on a 3-dimensional reconstruction of the ventral surface of the brain (A)
and on a coronal slice (B). L indicates left; R, right.
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Interrater reliability was computed for the ROIs by 3 independent raters
(C.U.L., K.K., and T.O.), who were blind to group membership. Ten cases were
selected randomly for interrater reliability. An intraclass correlation coefficient
was used to compute interrater reliability for the 3 raters: 0.979 for the
left FG and 0.985 for the right FG.
STATISTICAL ANALYSES
We used 1-way analysis of variance to test for group differences in
age, SES, parental SES, and basic neuropsychological performance. In addition, t tests were used to assess patient group differences in
clinical measures, age first medicated, and medication dosage and duration
of use. Tests for group differences in ICC were conducted using a 1-way analysis
of covariance (ANCOVA), with age and parental SES as covariates.
For ROI analysis, a mixed-model ANCOVA was performed with group (schizophrenia,
affective psychosis, or control) as a between-subjects factor and hemisphere
(left or right) as a within-subjects factor. Age and parental SES were used
as covariates for all ANCOVAs. Follow-up analyses included 2-factor ANCOVA
for comparing 2 groups, 1-way ANCOVA for each side, and post hoc Tukey Honestly
Significant Difference tests. To correct for potential differences in brain
size, we used relative FG volumes, computed as [(absolute FG volume)/(ICC)]
x 100. Testing absolute volumes with ICC as a covariate did not change
the results reported in the following section. In addition, we reanalyzed
the data by excluding all women (leaving 21 controls, 17 patients with first-episode
schizophrenia, and 15 with first-episode affective psychosis) and found no
meaningful changes in the results. Accordingly, we present findings based
on all participants.
Exploratory analyses of the relationship between absolute volumes of
the FG and the psychopathologic scales were evaluated using the Spearman 
to diminish the effect of any outliers. Herein, we conservatively used P .001 as the cutoff value for statistical significance,
considering the presence of multiple comparisons.
RESULTS
There were no significant group differences in age (Table 1). Patients with first-episode schizophrenia had a significantly
lower SES than control subjects, consistent with reduced functioning secondary
to their illness. Parental SES was upper middle class or above for all groups,
but patients with schizophrenia had a lower parental SES than control subjects.
There were no significant differences between patients with schizophrenia
and patients with affective psychosis on any of the clinical scales, age first
medicated, or medication dosage or duration of use. The age, SES, parental
SES, age first medicated, duration of medication use, and dosage (chlorpromazine
equivalent) of medication did not correlate with FG volume in the patients.
There was a significant difference in ICC volume among the groups (ANCOVA,
F2,61 = 3.92; P = .03). The ICC volume
was smaller in patients with affective psychosis than in the control group
(Tukey Honestly Significant Difference, P<.05),
but there were no significant differences between patients with schizophrenia
and the control group or between patients with schizophrenia and those with
affective psychosis (Table 2).
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Table 2. Gray Matter Volume of the Fusiform Gyrus in the 3 Study Groups*
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VOLUME OF THE FG
The 2-factor (3 groups x 2 sides) ANCOVA indicated a significant
main effect of group (F2,61 = 4.23; P
= .02) and a significant main effect of side (F1,61 = 4.82; P = .03) and no group-by-side interaction (F2,61
= 2.42; P = .10). Because we found a significant
main effect of group, we performed follow-up ANCOVAs (2 groups x 2 sides)
comparing each pair of groups separately. The results revealed that overall
FG gray matter volume was significantly smaller in patients with schizophrenia
than in those with affective psychosis (F1,38 = 5.16; P = .03) and control subjects (F1,42 = 5.90; P = .02), whereas there were no significant differences between patients
with affective psychosis and the control group (F1,40 = 0.80; P = .38). Thus, there was a statistically significant reduced
overall FG volume in schizophrenia. The schizophrenia group showed reduced
total FG (left + right) volumes of 9% (effect size, 0.93) relative to the
control group and 7% (effect size, 0.82) relative to the affective psychosis
group (Figure 2).
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Figure 2. Fusiform gyrus relative volumes
for each individual in the 3 study groups. Horizontal bars are means. L indicates
left; R, right.
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The significant main effect for side by ANCOVA indicates that the right
FG was larger than the left FG in all groups. Although there was no group-by-side
interaction, we performed follow-up 1-way ANCOVAs in the left and right FGs,
separately. The result revealed that the left FG differed among groups (F2,61 = 6.63; P = .002), with the schizophrenia
group having significantly smaller volume than the control and affective psychosis
groups (Tukey Honestly Significant Difference, P<.05).
The schizophrenia group showed gray matter volume reduction of 11% in the
left FG compared with the control group (effect size, 1.06) and the same 11%
reduction compared with the affective psychosis group (effect size, 1.13).
On the other hand, in the right FG, there was no significant difference among
groups (F2,61 = 2.37; P = .10). The schizophrenia
group showed an 8% smaller gray matter volume difference in the right FG (effect
size, 0.74) compared with the control group (Table 2 and Figure 2).
CORRELATION BETWEEN FG VOLUME AND PSYCHOPATHOLOGIC MEASURES
In an exploratory analysis of correlations between FG gray matter volume
and psychopathologic measures, we found no statistically significant correlations
between FG gray matter volume reduction and factors or items of the Brief
Psychiatric Rating Scale in first-episode schizophrenia or in first-episode
affective disorder. There also were no statistically significant correlations
between FG gray matter volume reduction and Global Assessment Scale scores.
In addition, none of the cognitive tests were statistically significantly
correlated with FG gray matter volume in this study.
COMMENT
To our knowledge, this is the first MRI study of FG gray matter volume
in schizophrenia or affective psychosis and the first to report reduced FG
gray matter volume in patients with first-episode schizophrenia. Using high–spatial
resolution MRI with 3-dimensional information, we reported bilateral FG gray
matter volume reduction in schizophrenia that was statistically significantly
smaller than that in patients with affective psychosis and in control subjects.
Our results suggest that FG gray matter volume reduction is specific to schizophrenia,
as contrasted with affective psychosis. The presence of FG gray matter volume
reduction in the course of first-episode schizophrenia suggests that this
abnormality is related to schizophrenia and is not a product of the potentially
confounding factors of long-term treatment or chronic illness.
The present data are consistent with findings of previous postmortem
studies18-19 in terms of FG abnormalities
in schizophrenia, although there is some difference in laterality. McDonald
et al19 reported a 13.2% smaller left FG gray
matter volume in 31 patients with schizophrenia, whereas there was no volume
decrease on the right FG. In addition, these investigators reported a reversal
of the normal left>right volume asymmetry in patients with schizophrenia.
In the present study, all 3 samples showed larger FG gray matter volumes on
the right, suggesting that there is a normal right>left FG asymmetry in all
3 groups. Other structural MRI studies42-43
in healthy populations also support the right>left FG volume asymmetry, although
the postmortem studies did not confirm this finding. Kim and colleagues,42 in a study that used similar FG measurement methods
as our study, reported that the FG is larger in the right hemisphere than
in the left in healthy individuals. This discrepancy between postmortem and
MRI studies stems in part from different anatomical boundaries and measurements.
Theoretically, it seems plausible that the right>left asymmetry of the
FG in right-handed control subjects may be due to the right hemisphere predominance
in visuospatial function, including facial recognition processes. But this
is conjecture because there is no clear-cut evidence that the larger side
need also be the dominant side.44 Possible
FG asymmetry in controls requires further investigation.
With respect to participants in the present study, those with first-episode
schizophrenia demonstrated 9% bilateral FG (left, 11%; right, 8%) gray matter
volume reduction compared with controls. The percentage reduction on the left
was slightly greater than that on the right, a result that is visually evident
in Figure 2 as the lower values
of the first-episode schizophrenia mean vs the other groups on the left. These
data suggest that there may be a slight trend for the schizophrenia group
to show a left>right FG gray matter volume reduction, although the absence
of a group-by-side interaction in the statistical ANCOVA makes this interpretation
a tentative one.
The bilateral FG gray matter volume reduction in the present study is
similar to the finding in a previous study28
of a bilateral Heschl's gyrus gray matter volume reduction in first-episode
schizophrenia compared with controls and patients with first-episode affective
psychosis. On the other hand, previous studies28
of first-episode schizophrenia compared with first-episode affective psychosis
and control subjects have found left-lateralized volume reduction in schizophrenia
of the posterior superior temporal gyrus27
and planum temporale. These data, and the findings of the present study, suggest
that areas not particularly specific for language may show bilateral reduction,
whereas language-specific areas with left lateralized functional dominance
show more preferential left side reduction.
In the present study, we found that FG gray matter volume reduction
was specific to schizophrenia. This finding further supports the results of
previous first-episode studies18-19
that indicate volume reduction in temporal lobe regions (ie, in those studies,
the left superior temporal gyrus and left planum temporale, Heschl's gyrus)
is specific to schizophrenia relative to affective psychosis. Other investigators
also suggest the specificity of MRI abnormalities to schizophrenia compared
with affective psychosis. For example, Zipursky et al45
found regional volume reduction in gray matter in patients with schizophrenia
but not in those with bipolar disorder and a decrease in global gray matter
volume in schizophrenia. Harvey et al46 similarly
reported a decrease in cortical volume in patients with chronic schizophrenia
but not in bipolar patients.
The present first-episode study did not find significant correlations
between clinical measures and FG volume reduction. This limitation might be
due in part to the instability of symptoms in first-episode psychosis.18-19,47 However, we believe
it is more likely that standard clinical scales, such as those used in the
present study, are limited in their ability to measure the functional specificity
of face processing ascribed to the FG. Future studies should measure face
processing and FG volumes, since, as described at the beginning of this article,
there is substantial neuropsychological and behavioral evidence that patients
with schizophrenia have deficits in face processing.9-11
With respect to ROI methods, we used reliable but arbitrary landmarks
because current MRI acquisition protocols do not allow for the definition
of anterior and posterior FG boundaries completely and accurately using textbook
anatomical criteria. We emphasize that because the boundaries were consistent
for all the study groups, we think it is highly unlikely that the small amounts
of the anterior and posterior parts of the FG that were excluded in the present
study were responsible for group differences. Finally, because of the small
numbers of patients and controls, the present study was unable to comment
on possible differences according to sex or on volume measures in unipolar
depression.
In summary, the overall FG gray matter volume reduction in first-episode
schizophrenia, but not in first-episode affective psychosis, suggests that
structural abnormalities in this region are specific to schizophrenia and
are evident at the time of first hospitalization.
AUTHOR INFORMATION
Submitted for publication January 31, 2001; final revision received
September 17, 2001; accepted October 12, 2001.
This study was supported in part by grants K02 MH 01110 and R01 MH 50747
(Dr Shenton), R01 MH 40799 (Dr McCarley), and R01RR11747 and IP41PR13218 (Dr
Kikinis) from the National Institutes of Health, Bethesda, Md; the Department
of Veterans Affairs Merit Awards (Drs Shenton and McCarley) and Middleton
Award (Dr McCarley) (Washington, DC); the Welfide Medicinal Research Foundation,
Japan (Dr Kasai); and the Uehara Memorial Foundation, Japan (Dr Kasai).
Corresponding authors and reprints: Robert W. McCarley, MD, and Martha
E. Shenton, PhD, Department of Psychiatry (116A), VA Boston Healthcare System,
Brockton Division, Harvard Medical School, 940 Belmont St, Brockton, MA 02301
(e-mail: robert_mccarley{at}hms.harvard.edu and martha_shenton{at}hms.harvard.edu).
From the Clinical Neuroscience Division, Laboratory of Neuroscience,
Department of Psychiatry, VA Boston Healthcare System, Brockton Division,
and Harvard Medical School, Brockton, Mass (Drs Lee, Shenton, Salisbury, Kasai,
Onitsuka, Dickey, and McCarley); the Cognitive Neuroscience Laboratory (Dr
Salisbury) and the Brain Imaging Center (Dr Yurgelun-Todd), McLean Hospital,
Belmont, Mass; and the Surgical Planning Laboratory, MRI Division, Brigham
and Women's Hospital, Department of Radiology, Harvard Medical School, Boston,
Mass (Drs Shenton, Kikinis, and Jolesz). Dr Lee is now with the Department
of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul.
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