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Ask YC: tendonitis at a startup?
35 points by lsb on Jan 27, 2008 | hide | past | web | favorite | 62 comments
I've been at a startup 7 months, and I'm feeling that my wrists are rapidly deteriorating. How would one write code for 15 hrs/day in such a setting?



Get religion about good ergonomics.

First a little story: my wife got carpal tunnel so bad in the 90's, she was barely able to button a shirt for 3-4 months, and had to wear splints for almost a whole year. She worked for a high-tech firm and had to leave the corporate world because of her wrists. Things got a lot better, but she didn't type for 3-4 years after that episode. She can type now for 1-2 hours a day, tops. After that, she has pain.

Hackers are like surgeons: worthless without their hands. Your wrists and hands are your bread and butter. Take care of them.

Get religion about ergonomics. Read up online about it. There's tons of information, try a lot of things out and see if they help.

I use the smart glove: http://www.imakproducts.com/products/smart_glove.htm

Imak ergo beads: http://www.imakproducts.com/Products/WristCushionForKeyboard...

The MSFT natural keyboard: http://www.microsoft.com/hardware/mouseandkeyboard/productde...

I go back and forth between a track ball and a mouse.

I also got an ergotron monitor arm: http://www.ergotron.com/Products/DeskMounts/tabid/71/ctl/Pro... It's amazing how much less my neck hurts, and how much easier it is on my eyes, because I can change the monitor's position so easily, I do it a lot more often.

And, I couldn't quite afford an Aeron Chair, so I went to OfficeMax, and got a knock-off: http://www.officemax.com/omax/catalog/sku.jsp?skuId=20952042...

It makes a world of difference for my back, and a better sitting posture means that I lean on my wrists less, causing less wrist and hand pain.


There's one thing you haven't mentioned, which is buy the fastest possible computer you can afford.

I find that crappy, slow, unresponsive interfaces (I looking at you Windows XP networked folders) actually make my hands hurt just by being slow.

I'm not saying that buying a faster computer will fix your wrists, but a responsive interface should be considered ergonomic.


I might be the only person here who disagrees in some way with this. I noticed that myself and other people I know only started developing RSI-type symptoms after computers got "fast enough". By that I mean that before that point there were frequent long-ish pauses when one couldn't do anything very much; at a certain point computers got so fast that such pauses became uncommon, and now it only really happens to me when I switch the machine on and wait for it boot and login.

The problem is that pauses are recovery time for your body. The good news is that once you've realised this, you can artificially introduce pauses into your routine, and give your body the chance to repair some of the damage caused by typing. I had big problems when I was a mere 21, and didn't use a computer for several months. With reading around, a bit of common sense, and a very gradual return to things, I not only got back to where I was, but now I use a computer and play guitar more than I did before. Getting better equipment is part of it (for me keyboard: http://maltron.com/ and a trackball: Logitech Trackman Wheel my preferred option), but the two most important things for me were: taking action as soon (i.e. on the day) I noticed problems; and taking breaks when doing things like typing. After a while you won't even notice the breaks are part of your routine.


This idea makes my inner cheapskate cry: I don't want to spend the money on a Mac Pro! And, yet, your argument is compelling.

Holding my hands over the keyboard or the mouse is tiring. I've found that, when the machine is unresponsive, I spend more time with my hands hovering over the controls, because when you have to make five clicks in succession -- waiting for the machine between each click -- you don't want to have to keep reaching out, making one click, reaching back and resting, then reaching out again... that's really slow. So you hold your hand there and wait. And if you have to wait two seconds between each click...

Well, darn it, now I've got to buy an eight-core Mac Pro! For my health!


Actually, the most responsive machine I have is my iMac 20".

The iMac is the 2.16 Core 2 version with the ATI graphics, and it wipes the floor with any other machine I've used, including my MBP and my work Dell (some kind of C2D Precision)


Ah, and that was exactly the machine I really wanted to buy. Sweet. Thanks for the advice.


That's interesting--I'd never thought of it in those terms.

I know that with video-games, the force I use to press the buttons varies _dramatically_ from game-to-game, even though the controller stays the same (depends on personal stress, responsiveness of the on-screen UI, etc).

I suppose a case could be made that unresponsive interfaces tend to make a person type/click more deliberately (i.e. forcefully) than is technically required by the input device.


Getting serious about ergonomics is an interesting combination of large up-front expense and cheap little hacks and exercises.

Budget $2000. I'm serious about this. The things you buy will last you for years, and $2000 will pay for itself if it saves you two weeks of sick time or a couple of doctor visits.

You may not actually have to spend all of that, but you are going to want:

* An excellent chair ($800 range. Feel free to try the cheaper chairs... I have an Aeron but frankly have no idea if it's worth it. I bought it after using one at work for six months, and discovering it was okay. Testing chairs is difficult and expensive, so I recommend starting out in the midrange rather than spending months working your way up from the $50 OfficeMax chairs. If you find that the more expensive ones are 5% better for you, spend the money.)

The goal with chairs is adjustability. I recommend a chair with adjustable arms, because sometimes when my shoulders get sore I move them up to brace my elbows during rest periods.

* An excellent keyboard. MSFT natural keyboard is a great value, but I switched to the Kinesis Advantage Pro six months ago, and it kicks butt: http://www.kinesis-ergo.com/ ). It costs something like $350. It looks like it was designed by aliens. You will feel like an idiot for the first week as you relearn all your typing and gradually remap all the keys to your favorite locations. If you don't know how to touch type... you will learn. But then you will experience the joy of feeling like you are typing while barely moving your hands.

* I concur with the Ergotron monitor arms. Being able to adjust the monitor to exactly the right position is important.

* A proper keyboard drawer. You want the kind with the arm that lets you adjust the keyboard to arbitrary angles and heights, and slide it in and out. If you use the mouse, you want to be able to mount the mouse at one side. Something like the ones on this page: http://www.ergoindemand.com/keyboard-tray-adjustable-shelf.h... . I would tell you the brand I use, but I picked mine out of the trash by the side of the road. (Arlington, MA -- there are real advantages of living in a startup hub!)

Then you have to hack. Once you've spent money on the raw materials, ergonomics is a game of inches. I have one of those damned expensive Aeron chairs, but just this year I discovered that it doesn't provide enough upper back support, so I strapped a cushion to the top with a bungie cord :). Cost: maybe $20, and the pain is gone. My right arm got sore using the mouse. I discovered that if I took my mouse support off the keyboard drawer and reattached it using a different bolt and some homemade washers, I could raise it by four inches. And, just like that, the pain went away.

See a physical therapist. If you do nothing else, do this. The good ones are amazingly smart. Don't wear wacky gloves or wrist braces without consulting one. It turns out that most of my own occasional wrist pain is caused by nerve pinches in my neck, and treating the wrists is mostly a waste of time...

Oh, and of course: don't type on a laptop keyboard for more than an hour or two every week. Laptops are ergonomically terrifying. Sorry to have to break this one to you. :)


The Kinesis keyboard is available on Amazon for $269 from a third party seller:

http://www.amazon.com/Kinesis-Advantage-USB-Keyboard-black/d...


First, thanks for the great advice. But, any ergonomic advice at all for MacBook/MBP users (aside from just don't do it)? E.g. can anyone recommend a good keyboard replacement or app or something else?


Oh, my main machine is a MacBook. The secret is to realize that laptops are for occasional use in libraries or lectures or hotel rooms, not for real work. It turns out that there really is a reason why pros work in real offices with real desks instead of at a table in the local coffeeshop.

To save yourself from your Macbook, pretend it's a desktop as much as you can. Buy an external keyboard. (I recommend the Kinesis, of course, but even a cheapo standard keyboard is better than the one on the notebook itself.) Buy the nifty Ergotron arm that lets you sit the laptop, open, on a tray and then move the tray around in space until the screen is at the proper height and distance. (http://www.provantage.com/ergotron-45-192-194~7ERGT06R.htm )

Now, since you're stuck at a desk anyway, buy a real monitor -- I have a 20" widescreen -- and another Ergotron arm (they have very nice 2-packs -- follow links from here: http://www.codinghorror.com/blog/archives/000959.html) and mount that on your desk, then have the laptop drive it as a second monitor. Now you are more productive, because you have more screen space, and you also have a real desk with a real keyboard that you can mount where it needs to be: in your lap.

The problem with laptop keyboards isn't the keyboard, per se; it's the fact that the thing is attached to the screen. You either have to stare down into your lap or raise your arms almost to the level of the screen. Either of these things can eventually cripple you. Obviously, your mileage will vary depending on how old you are, how much you type, your physical condition, your genetic heritage and the phase of the moon -- but, once you even start to think that you're feeling pain, you should immediately get serious about ergonomics.

I've been thinking about how to travel and still get work done. It's not an easy problem to solve. Carrying around my Kinesis and some sort of contraption that lets me elevate the laptop and its screen would be great. A sort of clamp-on, foldable, lightweight, portable keyboard drawer that could attach to the edge of a hotel desk and hold the keyboard at lap level would be truly great... though perhaps rather difficult to implement.


This is great stuff. Thank you for posting this!

I normally have a dual-screen setup powered by desktops plus a nice keyboard + mouse.

But I'm in the process of moving abroad and will be living out of my laptop for a little while.

You see some people at startups working straight off their laptops, day in and out. After 1-2 days on my raw Macbook, I have no idea how they do it.


I'd strongly encourage you to rent some screens and a keyboard while you're abroad, buy them (used, if possible) and sell them used when you leave, buy them abroad and ship them home to yourself, ship them to your destination and then ship them back...

Whether or not you will be able to find any desk space abroad is, of course, a different problem.

Keyboards and monitors are now lightweight and cheap. I'm hoping to make this fact work for me when next I need to relocate temporarily...


Stands like the iCurve ( http://www.amazon.com/Griffin-Technology-iCurve-Laptop-Stand... ) take up almost zero space inside a suitcase.


"I would tell you the brand I use, but I picked mine out of the trash by the side of the road. (Arlington, MA -- there are real advantages of living in a startup hub!)" ;)


Another vote for the Kinesis.

Literally all there is to my job is typing, and after 4 days on a cheapo keyboard I couldn't type anymore. Switched to a Kinesis and have been fine for months.


I second the gloves. Whenever I start to get any pain, I just put on these gloves http://www.ergomall.com/store/shop.html and I feel fine. Just in case you are true nerd without fashion sense - don't get the teal colored ones!


I love the MS 'Natural Ergonomic Keyboard 4000'. It feels a bit goofy at first, but it's really nice once you get used to it (There's this riser thing that goes on the front, so it puts your hands in a position where they fall down from the wrist instead of angling up). I work IT for a small city government, and the dispatchers in the police department -love- them. Hit up newegg (or your preferred hardware seller) and search for fa6-00010. The included mouse isn't too bad either.

Another recommendation that may sound stupid but is actually great: get a gamer mousepad...one of those gigantic ones with a nice wrist rest. I use a Razer eXactMat, and I love it. The bigger mousepad makes it much easier to get in the habit of mousing with your arm, not your wrist.


+1 for sound advice. A few years back I could start feeling the strain in my wrists. I immediately cut back my computer usage and got myself some ergonomic gear. (specifically: natural keyboard, good mouse) The pain was very light at that stage, so it didn't take long (a few weeks max) to subside. With the ergonomic equipment, even with high usage, I don't feel a thing.



Ten years ago I got pains in my hands and after various visits to my GP I was referred to a specialist. He dutifully looked at my hands and arms and asked lots of questions about where the pain is, what I do for a living, what medication I'm on, do I have any family history.

He then told me I was an idiot. He didn't understand why I thought I could type for 15 hours a day. Why I expected my tendons to put up with this kind of punishment. I got the feeling that if he could he would have kicked me in the nuts. He told me he could give me medication to reduce swelling but what would the point be. The pain is there because you are pushing yourself too far! Hmm I thought. What an idiot (with a lot of letter after his name). He told me to stop being an idiot and come back in six months if there was any pain.

I was pretty young at the time, I went to my boss and we spoke about the specialist. He told me I was an bloody idiot (I'm English so we're allowed to say these kinds of things to each other btw). He said it's "..great that you want to work for 15 hours a day but think about it. Your body is telling you something". Then he told me something that changed my perspective on coding. He said "It's not how much you type it's what you type". This single sentence made me a better, healthier, more considered and sophisticated programmer.

For the last ten years I've been a better, more productive programmer and if I ever see that specialist again I will shake his hand with my very healthy pain free hands.

Good luck


One important point is to take breaks often - get someting like Workrave and set it to force you to stop typing for 30 second every 5 minutes and take a longer break every hour. This doesn't really affect productivity, as you can think about your code during the breaks, and in fact probably improves it.

I had mild tendonitis when I was writing up my PhD, and found that forcing myself to take breaks made a huge difference.


... and also, if you have a laptop, force yourself to only use it at a desk, not on the couch or in bed.


On the Mac I use AntiRSI: http://tech.inhelsinki.nl/antirsi/


First, I'll second the folks who have already responded by saying that you shouldn't be typing for 15 hours per day. Coding, perhaps, but easily 1/2 or 2/3 of the time you spend programming should be spent thinking, reading code, etc. If you're consistently banging out line after line of new code for >12 hours per day, something is horribly wrong with your workflow, and I can't imagine you're getting much of an opportunity to refactor and test your code as you go.

That being said, I've found that even 8-10 hours of steady typing can be too much for me, unless I'm using an ergonomic keyboard and good office furniture. If you can find any model of keyboard at all that works for you, buy it. Ditto for wrist rests, chairs, monitors, whatever. If it's expensive, make your employer pay for it. No manager worth their salt should look askance at spending $1-2k if it'll keep you in front of the keyboard for even an hour longer per day.

If you're working for yourself and therefore self-imposing these ridiculous hours and spending limits, then stop. Seriously, just stop. Think about whether the payoff is going to be big enough to make crippling yourself for life. Hell, if you're really sitting at a computer for 15 hours a day, you're probably at risk of getting blood clots in your legs from lack of motion. No startup is worth dying over, or even seriously degrading your quality of living in the future.


An addition to all the great advice: remap Caps Lock to act as Ctrl.


Or, like me, use the edge of your hand to press it :) (you know the little bone at the joint of the pinky with the rest of the palm? That's what I use to press the left Ctrl)


And make the windows-keys make something useful, too.


I found that the new apple keyboards really helped ease my wrists pain. They are so flat that I no longer needed a gel pad in front of my keyboard.


I love them too, but because the keys take so little force to press.


Think more, code less :) Often I find the more time you spend thinking, the less code you need to write, because you end up with an elegant solution. Sure sometimes you need to churn out the boring code as well... I'd say use a laptop. I simply can't use an old style desktop keyboard - key travel is way too far.


The most important thing for your wrists is to keep the bones in your palm relatively straight with respect to your forearm. If you bend your wrists up, bad things can happen.

I work about 8h per day while walking slowly on a treadmill: http://rura.org/blog/2007/11/14/the-treadmill-desk-exercise-... In that configuration, I need a keyboard tray that's angled away from me at a somewhat sharp angle, so I can keep my wrists straight and have my elbows open at about a 120 degree angle.


> The most important thing for your wrists is to keep the bones in your palm relatively straight with respect to your forearm. If you bend your wrists up, bad things can happen.

Indeed: if you have to reach up to type, you are destroying your wrists.

With a laptop, you are stuck in the unenviable position of having to choose between wrist pains and neck cramps, since the keyboard and monitor are separate.

For a laptop:

Get a wireless keyboard (a wired one will get annoying if you have spinny chairs or accidentally yank on the cord), with a built-in trackpad, and keep it in your lap to type.

Then get either an external display, or raise your laptop's existing display (a stack of phone books should do it), so that your eye level is about 1/3 down the screen.


Answer: You can't.

I have RSI flare up when I'm working particularly hard (I'm a business consultant), and it's not fun. Aside from taking NSAIDs, the only real cure that I've found is to stop typing and mousing so much. And working hard to me, means >10 hours a day, plus at least one weekend day.

If I slack off a bit, then the RSI goes away until the next timecrunch, burn, death-march, etc. ;-)

I also have a Logitech MarbleMan trackbar, and that does help, though after a mouse, the trackball is a tad annoying to use, especially one without a scrollwheel.


I remember having temporary pain from working alot and it would go away after a couple days...

The bad thing - at some point, it becames residual - no amount of rest (short of 6-12 months of keyboard abstinence) will let you recover. You have to start proactively manage - You've broken the proverbial straw on the camel's back.

That was years ago, I have a much-less painful, residual level of aching (2.5 on a scale of 1 to 10).

Nowadays, I manage my work, with occasional flare ups (4/10). My advice is to get WorkPace restbreak software to force you take breaks. Consider using an burst-proof exercise ball chair (forces you to work your abs) http://www.fitter1.com/Catalog/Items/FBCJ.aspx

Take Yoga classes, swimming (great full-body exercise, zero-impact). Alexander technique is good for gaining body awareness as well. If you slouch your head is like a bowling-ball weight that causes a domino-effect of strain on your entire backbone/spine.

The good thing, if there is a good thing about RSI symptoms, is that you may start to realize that you may not be able to be a programmer for as long as you wanted and you start to diversify and you will not take your programming job for granted. And you become a much more efficient programmer..


To prevent this kind of thing in the first place: Stop typing at regular intervals, stand up, and run your fingers and wrists through a range of flexion and extension motions while moving your arms around, especially over your head and back down again. This will get more blood flowing in the area, which helps. Strength training of your wrists, shoulders, abs and back helps. Wear wrist braces at night. People often push their wrists into strange positions while asleep - this will prevent that. But do not wear them any other time - they will cause muscle atrophy which makes things worse.

You've waited a while though, so you'll probably need to stop typing entirely for a month to let the inflammation go away first.

JWZ is worth reading on this. http://www.jwz.org/gruntle/wrists.html

My final advice: try occupational therapists and physical therapists. Physicians aren't as good about knowing specifically what to change about your behavior and how to get you to do it. The better occupational and physical therapists think about these issues constantly.


If you often bang keys for 20 seconds, then sit still thinking for 40 seconds, try adjusting that split to 30+30. You're typing slower but you're not working slower.

Variety works well for me. I had a bad pain that was triggered by depressing the left mouse button. I now alternate my mouse between hands on a roughly weekly basis. After the first few days mousing left handed, it was no longer slowing me down.

Also, I find alternating seat height, keyboard type and position, screen height, etc eases the general back and neck pains that can come with sitting in the same position for too long. Whether 3+3+3+3 hours in varied positions is better than 12 hours in the same, "optimal" position is probably something physiotherapists would never agree on.

On medication: you don't want to use painkillers to enable your pushing too hard. On the other hand, my understanding is that inflammation is a bit of a vicious circle (inflamed tissues are more easily further irritated), so anti-inflammatories are your friends. Topical medication may be more or less effective than pills, and are less likely to screw up your stomach.


Anyone who thinks they have RSI should read Dr. Sarno's theories about RSI: http://podolsky.everybody.org/rsi/

All is not as it seems with RSI, and you should trust what the scientific research shows, not what your physical therapist with a PTA degree tells you.


Better take care of this asap. I've got medial epicondylitis, better known as golfer's elbow from typing to much. I've tried everything to get rid of it including 4 months of PT, but it always comes back. It sucks. I'll try anything at this point.


At an old job in 2003, my office mate quit and left these amazing hand rests which I began to use. I loved them so much that when they broke in 2006 I actually super glued them back together. At that time I couldn't find anyone selling them on the web. Now, they've broken again and it looks like I can get them here: http://www.ausconn.com/ - see the "Comfort glide" area - third picture from the top left (I know, amazing website). Apparently they're made in Australia. Seriously, these things are amazing.


I've been plagued with tendonitis on and off since I started typing like 20 years ago. The number one thing that I've found has helped is keeping track of my wrist alignment. Make sure your wrists are on a straight plane.

The easy way to describe it is that your wrists should be simliar to their natural resting position while you type.

A common problem that people have is that they use their wrist and elbow muscles while they type, and it puts a ton of stress on the joints and tendons.


Colemak layout works wonders, and for me was much more pleasant than Dvorak (plus, the transition is easier).

http://colemak.com/


How informed is your impression of Dvorak? I see that Colemak can be easier to learn for querty-typists, but the other points in the FAQ do not seem that vital.

(FAQ: http://colemak.com/FAQ#What.27s_wrong_with_the_Dvorak_layout...)

P.S. I do not want to start a flame war. Pretty much everything is better than querty.


I spent about 4 weeks working on the transition to Dvorak, and it never 'clicked' for me, and at the end I was in the 40s for my WPM touch-typing Dvorak whereas I'm about 85 on QWERTY. After 2 weeks in Colemak, I'm at 40 WPM and growing.

If "learning curve" is stopping you from switching keyboard layouts (as it was me), don't let it: Colemak decreases that transition time to bearable levels.


I switched to Dvorak some years ago. Because the keys on the keyboard did not match what you got when you pressed them - Dvorak forced me to touch type - which I hadn't been able to do on querty (or rather quertz) for lack of pressure.

Now I am much better at querty and Dvorak. You do not unlearn the old layout. In fact I find that I can alternate between both layouts as fast as I can tell the computer to switch. (I assigned the windows-key for switching.)


I am a long-time kinesis user because I find the kinesis i the best combination of speed and comfort. But once I head really crippling RSI, I switched to the safetype keyboard (www.safetype.com) for a few weeks, and found it even more comfortable. Eventually I switched back to the kinesis because of the speed and accuracy, but the safetype is worth a try if you have really bad pains.

www.safetype.com


I love all of Microsoft's ergonomic keyboards and highly recommend one. They lead to your hands being in a more natural position than on a straight keyboard. Nowadays, I can't type for more than maybe an hour on a regular keyboard before my wrists start to hurt, but I have no problems on ergonomic ones.


I've found that resting my arms at the same height as the keyboard really helps.


I didn't know this could be as big of a deal as it is. Now I know; thanks isb.


Whenever this question comes up I recommend the Alexander Technique. That worked for me, reply with email for more info.


This from the ACT RSI group (Australia):

Some treatments were moderately or very successful for most who tried them, with very little or no adverse effect. These were:

    * Bowen Therapy
    * Alexander Technique
    * Tai Chi
    * Self Hypnosis
Treatments with adverse effects on more than 20% of those who tried them included:

    * Swimming
    * Carpal tunnel surgery
    * Local anaesthetic injections
    * Traction (the standout villain!)
    * Stretches from a physio
    * Cortisone injections
http://www.rsi.org.au/treatments.html


There is now some good science to show that Alexander Technique is effective, at least for lower back pain:

http://alexandertechniquenorthside.ie/back-pain.html


Don't use Emacs.


Yes and no. The default Emacs setup on a standard keyboard can be a problem -- the pinkies, how they ache! -- but I find that using the mouse is even worse, so if my emacs alternative involves mousing I have an even bigger problem.

You have not lived until you've used Emacs with the Kinesis keyboard. You can remap any key to any other key instantly within the keyboard itself, without mucking around in your OS. And there are bunches of thumb keys. All those wacky control and meta keys now live, in mirrored pairs, under my thumbs, and the Caps Lock function has been moved to a random, faraway key, to be replaced by my own personal prefix key that I can use to trigger stuff like snippets and abbreviations.


Yes, emacs with a kinesis keyboard is great. Hitting the modifier keys with your thumbs instead of your pinkies makes a big difference because thumbs are your strongest fingers.


If you need to hit modifier keys a lot on a normal keyboard, move your whole hand and press them with your index and middle fingers together, instead of using your pinky.


Moving my whole hand is slow..



Do yoga and pilates and stretching exercises every day


Maybe in-between coding sessions...

Give yourself a little massage every now and then to relax the accumulated tension.


1) ergonomics. for example, if you have a laptop, keep in mind you should put the screen at the right height (ie, on some books or something) and then use external keyboard+mouse)

2) ergonomics. type with straight wrists. if you rest your palms on the table by the keyboard and bend your wrists up, while typing, that will hurt you

3) attitude and mood are important. when i was really scared of the pain, and obsessing about it, it made it a lot worse. at some point i relaxed and it felt a lot better. obviously that won't work in all cases, and you still have to be careful, but if you're scared every little nerve impulse means you're too crippled to work and your life is ruined, you can imagine more pain than you have.

4) form habits. some ppl play with their hair while thinking, or shake their leg, or bite their tongue. when you're thinking about how to write the next piece of code, you want to be unconsciously stretching. make it something you do automatically when you aren't paying attention to what you're physically doing.

5) i don't like chair arm rests. partly they are too far apart, and they have to be unless your chair width really hugs your body. i use a pillow in my lap (and supported on the ends by the arm rests) at all times. it's from an old couch and not too hard or soft. it gives me somewhere comfortable to rest my arms whenever i'm not typing, as well. your mileage may vary, but feel free to improvise if it's comfortable.


Second the arm rest bit and stretching habits.




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