ABSTRACT
Background:
Rotator cuff syndrome is the most common cause of shoulder pain in the general population, affecting somewhere between 5% and 10% of individuals under the age of 20 and over 60% of patients over the age of 80. Globally, millions of individuals are impacted by the prevalence of rotator cuff syndrome and its associated diseases.
Aim:
We aimed at assessing the public awareness of rotator cuff syndrome and frozen shoulder as one of its severe complications in the general population of Saudi Arabia.
Materials and Methods:
A cross-sectional, online survey was conducted on 1228 Saudi participants, using a questionnaire developed by the study authors.
Results:
A total of 1228 were surveyed; 59.0% were male. The analysis showed that 29.2% of the study population were familiar with rotator cuff syndrome and 20.1% of the respondents knew someone with the condition. The overall awareness of rotator cuff syndrome and frozen shoulder was poor. The level of awareness was associated with younger age [F (1224) =16.76, P = .000] lower economic status [F (1161) =2.71, P = .04] region of residence [t (1162) =3.37, P = .01] knowing a relative with the condition [t (1219) =4.92, P = .000], and the source of information [t (1219) =4.92, P = .000].
Conclusion:
This preliminary study revealed an overall lack of awareness of rotator cuff syndrome and frozen shoulder in the general population of Saudi Arabia. The awareness level was associated with the age of the respondents, income, region of residence, knowing someone with rotator cuff injury, and source of information about the condition. Further research is warranted to replicate our findings.
Keywords: Awareness, frozen shoulder, rotator cuff, Saudi Arabia
Introduction
Rotator cuff tears are one of the most common shoulder girdle pathologies.[1] Which can be caused by trauma or degeneration, are common causes of chronic shoulder pain and disability, particularly as people get older.[2] The rotator cuff is caused by a combination of factors three. The major mechanism of the rotator cuff has been identified as a combination of extrinsic mechanical compression (i.e. narrowing of the subacromial space) and tendon overuse/overload.[3] The prevalence of rotator cuff tears in the general population is estimated to be between 5%3 and 39%.[4]
According to several studies, The prevalence of rotator cuff tears increases with age.[4] The success of rotator cuff repair treatment is dependent on regular communication between the surgical and rehabilitation teams.[5] Non-operative management can improve clinical outcomes but does not address the underlying tear.[6] Over 40% of asymptomatic partial thickness defects progress to full-thickness tears within 3 years. In those who fail to respond to non-operative measures, surgery may offer a solution. Because of its great public fitness impact, it’s far more important to apprehend the underlying elements that are related to rotator cuff tears.[4] Assessment of things related to rotator cuff tears can enhance our know-how of the mechanisms of this disease and inspire investigations on potential prevention strategies.[4] The purpose of this study was to behavior a scientific assessment to at assess the public awareness of rotator cuff syndrome and frozen shoulder as one of its severe complications in the general population of Saudi Arabia. This study helps to promote early identification and treatment by offering insightful information about the level of awareness regarding adhesive capsulitis and rotator cuff disorders. It helped researchers find gaps in their expertise and create focused instructional programs. Enhancing patient counseling, management strategies, and prompt referrals helped family doctors.
Materials and Methods
Study design: This study was a community-based, cross-sectional, descriptive study conducted in the Kingdom of Saudi Arabia. The study was conducted in October 2022.
Study population and sampling: Randomly chosen study participants were chosen from the general population of different regions of Saudi Arabi, who gave their consent. Candidates, who had declined to take part was excluded. Data were gathered using an online questionnaire that was designed by the researchers The questionnaire was designed and reviewed by independent experts in orthopedics, then it was translated into simple Arabic and distributed electronically on the Google Forms through social media. It consisted of multiple-choice questions on the sociodemographic details of the participants, such as gender, age, marital status, and level of the education. A separate section of the questionnaire consisted of questions assessing the participants’ level of awareness of rotator cuff syndrome and frozen shoulder. Source of knowledge about these conditions was also examined.
Statistical analysis
Data were analyzed using the Statistical Package of Social Sciences (SPSS) Version 26 (SPSS Inc., Chicago, IL). All eligible questionnaires were double-checked before coding. Frequencies and percentages were calculated for categorical variables. Each correct response to the awareness questions was scored one point. The mean and standard deviation were calculated for the total score. The relationship between the total score of the awareness scale and independent variables was determined using the independent samples t-test and analysis of variance (ANOVA) when applicable. Associations were considered statistically significant if the P value was less than 0.05.
Ethical consideration
The institutional review board (IRB) of the Directorate of Health Affairs in Aseer provided the ethical approval for this study. All participants provided electronic consent after being informed of the study’s objectives.
Results
The study enrolled 1228 participants; 59.0% were male. The age ranged from less than 18 to more than 45 years, with 47.5% in the age group 18 to 25 years. Bachelor’s/diploma was the most common educational qualification reported by 70.7%. A monthly income of less than 5000 Saudi Riyals (SAR) was reported by 44.0%, 5000–9000 SAR by 19.0%, and more than 9000 SAR by 31.7%. The sample consisted of 46.1% of respondents from the southern sector of Saudi Arabia, 25.2% the western sector, 16.9% the central sector, 6.9% the eastern sector, and 4.8% the northern sector. The baseline characteristics of the study sample are shown in Table 1.
Table 1.
Baseline characteristics of the study sample (n=1228)
| Variables | Frequency | Percent |
|---|---|---|
| Sex | ||
| Male | 725 | 59.0 |
| Female | 503 | 41.0 |
| Age group (years) | ||
| <18 | 55 | 4.5 |
| 18–25 | 583 | 47.5 |
| 26–45 | 388 | 31.6 |
| >45 | 202 | 16.4 |
| Education | ||
| Primary school | 24 | 2.0 |
| Middle school | 65 | 5.3 |
| High school or below | 238 | 19.4 |
| Bachelor’s or diploma | 868 | 70.7 |
| Master or doctorate | 27 | 2.2 |
| Monthly income (Saudi Riyals) | ||
| <5000 | 540 | 44.0 |
| 5000–9000 | 233 | 19.0 |
| >9000 | 389 | 31.7 |
| Region of residence | ||
| Central | 208 | 16.9 |
| Southern | 566 | 46.1 |
| Northern | 59 | 4.8 |
| Western | 310 | 25.2 |
| Eastern | 85 | 6.9 |
As shown in Table 2, 29.2% of the study population were familiar with rotator cuff syndrome. A total of 20.1% of the respondents knew someone with the condition, who was a first-degree relative to 9.6%, a second-degree relative 8.6%, and a non-relative 1.1% [Table 2].
Table 2.
Familiarity with the rotator cuff syndrome (n=1228)
| Questions/statements | Frequency | Percent |
|---|---|---|
| Are you familiar with rotator cuff as a medical syndrome? | ||
| No | 870 | 70.8 |
| Yes | 358 | 29.2 |
| Do you know someone who is affected by rotator cuff syndrome? | ||
| No | 981 | 79.9 |
| Yes | 247 | 20.1 |
| If answered yes to the previous question, what is the relationship degree of that person to you? | ||
| First degree | 118 | 9.6 |
| Second degree | 106 | 8.6 |
| Other “friends, acquaintances, etc.” | 13 | 1.1 |
Table 3 summarizes the respondents’ answers on questions about the definition, risk factors, and diagnosis of the rotator cuff syndrome. Most of the respondents (63.9%) did not know that the rotator cuff syndrome affects the muscles of the shoulder and interfere with the daily activity. Asked about the most common risk factors of the rotator cuff syndrome, 28.3% reported shoulder trauma, 24.3% heavy sports, 18.2% age, and 10.3% physical inactivity, while 47.6% did not know. The respondents, who knew there is a variation of severity of the rotator cuff among individuals consisted 47.7% of the study subjects. About one-fifth (20.4%) thought that the rotator cuff syndrome is diagnosed using clinical examination and MRI, 15.9% clinical examination and X-ray, and more than half (52.5%) did not know the correct diagnostic procedure in patients with suspected rotator cuff injury [Table 3].
Table 3.
Awareness of definition, risk factors, and diagnosis of the rotator cuff syndrome (n=1228)
| Questions/statements | Frequency | Percent |
|---|---|---|
| The rotator cuff syndrome affects the muscles of the shoulder and interfere with the daily activity | ||
| Do not know | 785 | 63.9 |
| No | 74 | 6.0 |
| Yes | 369 | 30.0 |
| What risk factors for the rotator cuff syndrome do you know?1 | ||
| Do not know | 584 | 47.6 |
| Age | 223 | 18.2 |
| Shoulder trauma | 347 | 28.3 |
| Heavy sports | 298 | 24.3 |
| Physical inactivity | 127 | 10.3 |
| Source of information about the rotator cuff syndrome | ||
| Doctors | 79 | 6.4 |
| Books and magazines | 61 | 5.0 |
| Internet | 187 | 15.2 |
| Relatives and friends | 55 | 4.5 |
| Work or study | 6 | 0.5 |
| The severity of the rotator cuff syndrome varies from person to person | ||
| Do not know | 571 | 46.5 |
| No | 71 | 5.8 |
| Yes | 586 | 47.7 |
| How is the rotator cuff syndrome diagnosed? | ||
| Do not know | 645 | 52.5 |
| Clinical examination only | 85 | 6.9 |
| X-ray only | 52 | 4.2 |
| Clinical examination and X-ray | 195 | 15.9 |
| Clinical examination and MRI | 251 | 20.4 |
1Percentage is calculated for each response separately. MRI: magnetic resonance imaging
The analysis of responses to questions about the treatment of rotator cuff syndrome showed that about half (49.5%) of the respondents did not know the available treatment options, 35.5% chose physiotherapy, 20.6% surgical repair, 18.6% analgesia, and 6.4 heavy exercise. A total of 27.2% thought that surgical management of the rotator cuff injury is indicated when non-operative methods fail, 12.0% thought it is indicated for repairing the torn tendon, while 9.9% considered both situations as possible indications for surgery in patients with rotator cuff. While most of the respondents (60.7%) did not know whether physiotherapy would be a better option compared to surgery in rotator cuff patients, 31.0% agreed with this statement [Table 4].
Table 4.
Awareness of the treatment of the rotator cuff syndrome (n=1228)
| Questions/statements | Frequency | Percent |
|---|---|---|
| What are the treatment options for a patient with the rotator cuff syndrome? | ||
| Do not know | 608 | 49.5 |
| Analgesics | 229 | 18.6 |
| Physiotherapy | 436 | 35.5 |
| Surgical treatment. | 253 | 20.6 |
| Heavy exercise | 78 | 6.4 |
| What are the indications for surgical repair of the rotator cuff syndrome? | ||
| Do not know | 626 | 51.0 |
| Failed of the non-operative management | 334 | 27.2 |
| Surgical repair of the torn tendon | 147 | 12.0 |
| The previous two options | 121 | 9.9 |
| Considering clinical outcomes, choosing physiotherapy in treating the rotator cuff syndrome is better than surgical repair. | ||
| Do not know | 746 | 60.7 |
| No | 101 | 8.2 |
| Yes | 381 | 31.0 |
1Percentage is calculated for each response separately
As shown in Table 5, 27.9% have heard about the frozen shoulder and 28.7% knew that it presents as shoulder pain with movement in all directions. Regarding the risk factors of the frozen shoulder, more than half of the respondents (54.8%) did not know the exact factors, 28.6 chose rheumatoid arthritis, 19.7% osteoporosis, 12.8% diabetes, and 8.1% endocrine disorders [Table 5].
Table 5.
Awareness of the frozen shoulder as a complication of the rotator cuff syndrome (n=1228)
| Questions/statements | Frequency | Percent |
|---|---|---|
| Have you heard about the frozen shoulder as a medical condition? | ||
| No | 886 | 72.1 |
| Yes | 342 | 27.9 |
| Did you know that the frozen shoulder is a condition where the pain is associated with any movement? | ||
| Do not know | 681 | 55.5 |
| No | 194 | 15.8 |
| Yes | 353 | 28.7 |
| What risk factors for the frozen shoulder do you know?1 | ||
| Do not know | 673 | 54.8 |
| Diabetes mellitus | 157 | 12.8 |
| Rheumatoid arthritis | 351 | 28.6 |
| Endocrine diseases | 100 | 8.1 |
| Osteoporosis | 242 | 19.7 |
1Percentage is calculated for each response separately
A series of independent samples t-tests and analyses of variance were performed to look for the difference in the awareness mean across different study variables. Age, income, region of residence, knowing someone with rotator cuff injury, and source of information about the rotator cuff injury were significantly associated with awareness of the rotator cuff injury. The mean score of awareness was higher, among younger subjects [F (1224) = 16.76, P = .000]. In terms of income, those who had lower income were more likely to score higher on the awareness scale [F (1161) =2.71, P = .04]. The mean of the awareness score was also significantly different across different regions of Saudi Arabia. Subjects from the northern region had the highest score (M = 4.88, SD = 3.68), followed by those from the central region (M = 4.45, SD = 4.25), southern region (M = 3.78, SD = 3.72), and western region (M = 3.52, SD = 3.68)[t (1162) =3.37, P = .01]. Furthermore, subjects who knew someone with rotator cuff injury (M = 7.74, SD = 3.28) were more likely to score higher on the awareness scale compared to those who did not (M = 2.31, SD = 2.79) [t (1126) =29.37, P = .000]. The mean score of awareness of rotator cuff injury differed among those who reported different sources of information. The highest scores were found in subjects, who took their information from work/study (M = 11.00, SD = 1.90), followed by doctors (M = 8.96, SD = 3.56), Internet (M = 6.96, SD = 2.83), books (M = 6.63, SD = 2.29), and relatives/friends (M = 6.30, SD = 2.26) [t (1219) =4.92, P = .000][ [Table 6].
Table 6.
Correlation between the subject’s characteristics and the mean of awareness of the rotator cuff injury (n=1228)
| Category | Variables | Mean | SD | t or F | df | Sig. | 95% CI | |
|---|---|---|---|---|---|---|---|---|
|
| ||||||||
| Lower | Upper | |||||||
| Sex | Male | 3.93 | 4.01 | 0.425 | 1226 | 0.67 | −.34 | 0.53 |
| Female | 3.84 | 3.59 | ||||||
| Age | <18 | 4.95 | 3.71 | 16.76 | 1224 | 0.000 | 3.94 | 5.95 |
| 18–25 | 4.60 | 3.99 | 4.27 | 4.92 | ||||
| 26–45 | 3.10 | 3.44 | 2.76 | 3.45 | ||||
| >45 | 3.11 | 3.76 | 2.59 | 3.63 | ||||
| Education | Primary school | 4.71 | 3.69 | 1.4 | 1219 | 0.22 | 3.15 | 6.27 |
| Middle school | 3.72 | 3.03 | 2.97 | 4.47 | ||||
| High school or below | 4.24 | 4.01 | 3.73 | 4.75 | ||||
| Bachelor’s or diploma | 3.83 | 3.85 | 3.57 | 4.09 | ||||
| Master or doctorate | 2.59 | 3.81 | 1.09 | 4.10 | ||||
| Income (SAR) | <5000 | 4.21 | 3.90 | 2.71 | 1162 | 0.04 | 3.88 | 4.54 |
| 5000–9000 | 3.81 | 3.69 | 3.33 | 4.28 | ||||
| >9000 | 3.53 | 3.93 | 3.14 | 3.92 | ||||
| Region | Central | 4.54 | 4.25 | 3.37 | 1223 | 0.01 | 3.96 | 5.12 |
| Southern | 3.78 | 3.72 | 3.47 | 4.08 | ||||
| Northern | 4.88 | 3.68 | 3.92 | 5.84 | ||||
| Western | 3.52 | 3.68 | 3.11 | 3.93 | ||||
| Knowing someone with rotator cuff injury | Yes | 7.74 | 3.28 | 29.37 | 1226 | 0.000 | 5.07 | 5.79 |
| No | 2.31 | 2.79 | ||||||
| Source of information | Doctors | 8.96 | 3.56 | 4.92 | 1219 | 0.000 | 5.52 | 7.12 |
| Books | 6.63 | 2.29 | 7.56 | 10.37 | ||||
| Internet | 6.96 | 2.83 | 5.88 | 7.39 | ||||
| Relatives and friends | 6.30 | 2.26 | 6.47 | 7.46 | ||||
| Work/study | 11.00 | 1.90 | 5.72 | 6.87 | ||||
SD: standard deviation, t: independent t-test, F: one-way analysis of variance (ANOVA), df: degrees of freedom, CI: confidence interval, SAR: Saudi Riyals
Discussion
Any injury or degenerative condition affecting the rotator cuff is referred to as rotator cuff syndrome. This comprises partial or full-thickness rotator cuff tears, rotator cuff tendonitis, subacromial impingement syndrome, and bursitis. The probability of developing rotator cuff arthropathy and glenohumeral degenerative disease is increased by chronic rotator cuff syndrome. Patients with long-standing, untreated rotator cuff syndrome may restrict shoulder movement, ultimately leading to adhesive capsulitis (frozen shoulder), which necessitates orthopedic referral.[7,8,9,10] Globally, millions of individuals are impacted by the prevalence of rotator cuff syndrome and its associated diseases.[11] In the United States alone, shoulder pain causes over 4.5 million office visits and costs the healthcare system nearly $3 billion.[12] Rotator cuff syndrome is the most common cause of shoulder pain in the general population,[13] and it affects patient populations in an age-dependent manner, affecting somewhere between 5% and 10% of individuals under the age of 20 and over 60% of patients over the age of 80. The lifetime prevalence of persistent shoulder discomfort in the adult population is 67%.[11,14,15]
The present study is the first in Saudi Arabia that was conducted using a sample of 1228 subjects from all regions of Saudi Arabia. We aimed at assessing the public awareness of rotator cuff syndrome and frozen shoulder as one of its severe complications. The participants were tested in different aspects of both disease entities, including definition, symptoms, risk factors, diagnostic methods, and treatment options. We also collected data about the source of information about the study subject to identify possible ways of intervention for improving the public awareness of such a devastating condition, which negatively impact quality of life of the affected individuals.[16]
The analysis showed that 29.2% of the study population were aware of rotator cuff syndrome as a health condition, indicating an overall poor awareness of the condition in the current study. A total of 20.1% of the respondents knew someone with rotator cuff syndrome who was a first-degree relative to 9.6% of the respondents, a second-degree relative to 8.6%, and a non-relative to 1.1%. This is consistent with the previous reports on the prevalence of rotator cuff syndrome in the general population that was reported to be between 5% and 10% of individuals under the age of 20 and over 60% of patients over the age of 80.[17] We are not aware of a study that estimated the prevalence of rotator cuff syndrome in Saudi Arabia to compare these findings to it. However, as this is the first study of its kind in the region, it could serve as preliminary research, and we recommend future studies to use it as a model to conduct epidemiological surveys assessing the prevalence and sociodemographic aspects of the condition in Saudi Arabia. We have good reasons to believe that there is a strong relationship between the awareness of rotator cuff syndrome and knowing someone who had it. In fact, the mean of the awareness scale was higher among those who knew a relative with the condition (M = 7.74, SD = 3.28) was significantly higher than those who did not (M = 2.31, SD = 2.79). This could explain the similarity between the percentage of subjects who reported familiarity with rotator cuff syndrome and those who had a relative affected by it.
The study demonstrated an overall lack of awareness of important aspects of rotator cuff syndrome. Most of our respondents (63.9%) did not know the definition of rotator cuff syndrome, did not identify common risk factors for the condition (47.6%), the variable nature of the condition (46.5%), and its diagnosis (52.5%). Age is one of the well-known risk factors for developing rotator cuff syndrome. As mentioned, the condition affects over 60% of people over 80 years.[17] Heavy sports is another risk factor for rotator cuff, especially in the young population. In overhead athletics, rotator cuff syndrome is frequently encountered. Observational evidence supports the clinical association between overhead sport and shoulder pain, specifically rotator cuff pathology, despite the scarcity of high-quality, sport-specific investigations assessing the frequency of rotator cuff tendinopathy.[18,19,20,21] Activities including baseball,[22] tennis,[20] swimming,[21] golf,[19] and men’s gymnastics[18] are linked to rotator cuff tendon injuries. Based on these observations, it is believed that repetitive, sport-specific movements that result in subacromial compression or dynamic eccentric strain on the rotator cuff frequently cause pain and disease of the rotator cuff tendons.
The study highlighted several gaps of awareness regarding the treatment of rotator cuff syndrome in the current sample. Half of the respondents (49.5%) did not know treatment options for patients with rotator cuff injury and 51% did not know when surgery is indicated. Conservative treatment with ice, rest, and nonsteroidal anti-inflammatory medicines are the first lines of treatment for rotator cuff tendinopathy.[23] Physical therapy is the main treatment once rotator cuff tendinopathy has been clinically diagnosed. Although quality controlled clinical trials of physical therapy programs for rotator cuff tendinopathy are relatively few, a systematic review of ten randomized trials found that exercise therapy enhanced symptoms and function in laborers with rotator cuff tendinopathy, as well as aided in their return to work.[24] Another review of 64 randomized trials evaluating a wide range of physical therapy interventions for subacromial shoulder pain, such as rotator cuff tendinopathy, found that exercise was as valuable as surgery and better than placebo or no treatment.[25] Surgical interventions are reserved for patients, who did not respond to physiotherapy. Surgical techniques for rotator cuff syndrome include debridement, subacromial decompression, and/or acromioplasty, as well as rotator cuff debridement and, when indicated, rotator cuff bursal- or articular-sided tear completion with rotator cuff repair.[26]
Regarding frozen shoulder, most of our respondents were not aware of the condition (72.1%), its symptoms (55.5%), and its risk factors (54.8%). Frozen shoulder (adhesive capsulitis) is an inflammatory condition that causes stiffness, pain, and a significant loss of passive range of motion in the shoulder. Long-term disability has been reported in patients at 10% to 20%, with symptoms persisting at 30% to 60%.[27] The lifetime prevalence of frozen shoulder in the general population is 2% to 5%.[28] Frozen shoulder can be idiopathic, but it is frequently associated with other diseases and conditions. Diabetes mellitus patients are more likely to develop frozen shoulder.[29] The condition has also been associated with endocrine diseases.[30] Frozen shoulder can also develop because of shoulder injuries such as rotator cuff tears, proximal humerus fractures, or surgery.[31,32]
The study demonstrated a relationship between awareness of rotator cuff and some of the respondents’ sociodemographic variables. Age was significantly associated with awareness level. Higher awareness scores were more likely to be found in younger patients (P = .000). Although the condition affects older patients more commonly, young adults may be more likely to hear about it or learn it at school. This is supported by the finding that higher awareness scores were found in those who reported work/study as their main source of information, which itself was a significant factor associated with awareness of rotator cuff syndrome (P = .000). interestingly, subjects with low economic status (income <5000 SAR) were more likely to have high awareness of rotator cuff syndrome compared to those with higher incomes. This could be indirectly related to the respondents age (18–25 years) in which the individual is expected to be studying and not employed yet. Alternatively, it could indicate a higher prevalence of rotator cuff syndrome among individuals with low economic status, hence the familiarity with the condition from the patients themselves and their relatives, who had the condition. However, these findings need to be replicated by future studies to further examine the nature of their relationship with awareness of rotator cuff syndrome. The source of information was statistically associated with the mean score of awareness of clubfoot syndrome, with work/study being associated with the highest score (M = 11.00, SD = 1.90), followed by doctors (M = 8.96, SD = 3.56), Internet (M r = 6.96, SD = 2.83), books (M = 6.63, SD = 2.29), and relatives/friends (M = 6.30, SD = 2.26). As expected, better knowledge of health conditions is what the public receive from reliable sources of information like health professionals. Studying and working in the health sectors gives access to clinical information that are not usually available to the public. In the study, taking information about rotator cuff syndrome from relatives/friends was associated with worst awareness, making them a non-reliable source of information. These findings are preliminary and not yet confirmed by well-designed studies. Thus, they should be replicated and supported with sufficient evidence to be eligible for designing proper interventions aiming at raising the public awareness of rotator cuff syndrome and frozen shoulder.
Although the study included individuals from all around Saudi Arabia in a sufficient sample to investigate the awareness of rotator cuff syndrome among the general population of Saudi Arabia, some limitations should be addressed. First, the study is the first in the region and we are not aware of similar studies locally and even globally, making comparison of our findings with the previous research inapplicable. Second, even though we conducted the study using a large sample size, it was not representative of all Saudis as it was an online survey, excluding those who do not have access to the Internet and those with limited education. Finally, we used a questionnaire which was not validated by other researchers.
Conclusion
This preliminary study revealed an overall lack of awareness of rotator cuff syndrome and frozen shoulder in the general population of Saudi Arabia. The awareness level was associated with the age of the respondents, income, region of residence, knowing someone with rotator cuff injury, and source of information about the condition. Further research is warranted to replicate our findings.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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