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OUTLINE

 1.  Abstract
 2.  
 3.  KEYWORDS
 4.  List of abbreviations
 5.  Methods
 6.  Results
 7.  Discussion
 8.  Conclusions
 9.  Appendix. Supplementary materials
 10. References

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FIGURES (1)

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TABLES (1)

 1. Table 1




EXTRAS (2)

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ARCHIVES OF REHABILITATION RESEARCH AND CLINICAL TRANSLATION

Volume 4, Issue 3, September 2022, 100192

REVIEW ARTICLE (META-ANALYSIS)
TRAUMATIC BRAIN INJURY AFTER MUSIC-ASSOCIATED HEAD BANGING: A SCOPING REVIEW

Author links open overlay panelJames B. Meiling DO a, David R. Schulze DO b,
Emily Hines MD a, Leslie C. Hassett MLS c, Dmitry Esterov DO a
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ABSTRACT


OBJECTIVE

To examine the literature to understand the extent that music-associated head
banging (MAHB), a common form of self-expression that involves rhythmically
swinging one's head to music, is a risk factor for traumatic brain injury (TBI),
to identify areas for further research, and to inform primary prevention
strategies.


DATA SOURCES

A comprehensive search of several databases from database inception to June 30,
2021, was designed and conducted by an experienced librarian with input from
study investigators.


STUDY SELECTION

Study inclusion criteria encompassed all study designs evaluating TBI associated
with MAHB. Two independent reviewers reviewed all titles, abstracts, and full
texts.


DATA EXTRACTION

Data were extracted by 2 independent reviewers, and results were summarized
descriptively.


DATA SYNTHESIS

Of 407 eligible studies, 13 met inclusion criteria. All included studies were
case reports from multiple countries describing a case of moderate-severe TBI
occurring as a direct consequence of MAHB. Of the individuals reported (n=13),
they had 1 or more of the following: traumatic subdural hematoma (n=8), internal
carotid artery dissection (n=2), basilar artery thrombosis (n=2), traumatic
vertebral artery aneurism (n=1), or intracerebral hemorrhage (n=1). No studies
were found involving mild TBI after MAHB.


CONCLUSIONS

This scoping review suggests that MAHB is a risk factor for moderate-severe TBI,
although the incidence of mild TBI after MAHB remains unknown. Additional
research is needed to understand the association of TBI after MAHB through the
spectrum of injury severity, including the potential sequelae of multiple
subconcussive injuries.

 * Previous article in issue
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KEYWORDS

Brain injuries, traumatic
Music
Rehabilitation
Review


LIST OF ABBREVIATIONS

CT
computed tomography
MAHB
music-associated head banging
mTBI
mild traumatic brain injury
PRISMA
Preferred Reporting Items for Systematic Reviews and Meta-Analysis
TBI
traumatic brain injury
Up to 69 million individuals worldwide sustain a traumatic brain injury (TBI)
every year, making TBI a leading cause of global morbidity and mortality.1,2 The
leading causes of TBI worldwide are falls, motor vehicle collisions, and
sports-related injuries.1,3
Regardless of etiology or injury severity, TBI can result in chronic
neurobehavioral symptoms along with physical and cognitive impairment that can
persist years after injury.1,3, 4, 5, 6 These impairments can lead to restricted
societal participation, decreased driving, and lower levels of employment, all
of which account for a high prevalence of disability after TBI.7, 8, 9, 10
TBI is defined as a disruption in the normal function of the brain due to a
blunt or penetrating force, a nonimpact blast, or an inertial load.11,12 A
common mechanism of TBI is a whiplash injury, which is characterized by
acceleration and deceleration forces to the head and neck from either direct or
indirect contact, with a motion related inertial load that can result in diffuse
brain injury.13, 14, 15 There is evidence of blood flow changes and decreased
gray matter density associated with whiplash injury,14,16 suggesting traumatic
axonal injury in the setting of an inertial loading of vulnerable axons.13,14,17
Individuals who sustain a TBI associated with a whiplash injury can present with
symptoms that include headache, neck pain, dizziness, and increased cognitive
difficulties. Whiplash-associated TBI can also result in increased prevalence of
disability; thus, preventing TBI associated with whiplash injury remains an
important public health priority.18
While whiplash-associated TBI is most commonly associated with motor vehicle
collisions and sports-related concussions,19 a potentially unrecognized risk
factor for TBI may be in the sphere of nonoccupational high-intensity music,
including concerts, discotheques (clubs), and personal music players.20 A common
form of self-expression activity done throughout the world by both musicians and
music listeners in these settings is referred to as music-associated head
banging (MAHB), in which the listener swings ones head in a rhythmic—and often
high-velocity fashion—as directed by the beat of the song, particularly to rock,
punk, or heavy metal music. MAHB overall involves extremes in flexion and
extension of the cervical spine and when combined with acceleration/deceleration
motions, it has been reported to have a mechanism of injury similar to known
whiplash-associated TBI associated most commonly with motor vehicle collisions
or sports-related concussion.21 The authors found several case reports of MAHB
leading to severe TBI with resulting severe morbidity, although there have been
no systematic reports of the scope of MAHB as a potential risk factor for TBI.
The primary objective of this scoping review is to understand whether MAHB is a
risk factor for TBI of any severity, as well as to understand the extent of this
risk. Considering the popularity of concerts throughout the world and MAHB in
general, identifying the extent that MAHB is a risk factor for TBI could serve
to identify public health needs in this area and ultimately decrease the
incidence and resulting morbidity of TBI.


METHODS

To comprehensively search the literature and synthesize the evidence on this
topic, a scoping review was conducted according to the Preferred Reporting Items
for Systematic Reviews and Meta-Analyses for Scoping Reviews Statement.22 The
protocol for this scoping review has not been published.


DATA SOURCES AND SEARCH STRATEGY

A search of several literature databases from database inception to June 30,
2021, limited to English language and excluding animal studies, was designed and
conducted by an experienced librarian with input from study investigators. The
same strategy was rerun from database inception to September 2, 2021, to include
non-English language articles. The databases included Ovid MEDLINE (1946+) and
Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily, Ovid
Embase (1974+), Ovid Cochrane Central Register of Controlled Trials (1991+),
Ovid Cochrane Database of Systematic Reviews (2005+), Ovid APA PsycInfo (1967+),
and Web of Science, and Scopus (1788+). Because we found no synonyms for head
banging and adding terms that might indicate music such as rock, metal, or band
would only restrict the search and potentially miss articles, we performed the
most comprehensive search by using only variations of the term head banging. We
reviewed all retrieved articles and then screened for those related to MAHB. The
complete search strategy showing all search terms, date ranges, and limits for
each database is available in online supplemental appendix S1.


STUDY SELECTION

Study inclusion criteria included all age groups and encompassed the following
study designs: (1) randomized trials, (2) observational studies, (3) case
series, (4) case studies, and/or (5) conference abstracts studying TBI
associated with MAHB. Published studies examining all severity of TBI resulting
from MAHB were included. We included studies resulting from any traumatic
cervical related sequelae such as cerebral artery dissection as well in our
search, given the same mechanism of injury. Exclusion criteria included (1) TBI
due to other etiology, (2) head banging in contexts other than along to music,
(3) other non-TBI due to MAHB, and (4) MAHB not reporting TBI as a sequela. We
included all languages in our search and excluded animal studies.
Two independent reviewers screened each title and abstract identified by the
search strategy. Any disagreements between authors resulted in inclusion for
full-text review. Two independent reviewers subsequently screened each full text
of all studies included after title and abstract review. If inclusion criteria
were not clear from screening of abstract and titles, the article was included
for full-text review. Interrater reliability of full-text review for final
inclusion for data extraction was assessed. Interrater agreement between 2
independent reviewers was 90.5% (κ=80.0%; 95% CI, 54.2%-100%), indicating
substantial agreement. Disagreements were resolved by mutual consensus between 4
coauthors. The references of the included articles were also used to screen for
other potentially relevant articles.


DATA EXTRACTION

Data were extracted by 2 independent reviewers separately, with discrepancies in
data extraction resolved by mutual consensus. Abstracted data included
authorship, publication year, study design, sample size, patient demographics,
mechanism of injury, severity of injury, time between injury and symptom onset,
time between injury and presentation to physician, treatment plan, surgical
intervention if applicable, and details regarding outcome.
Because of the heterogeneity in studies defining TBI severity, the authors used
the Mayo classification system to uniformly classify TBI severity (supplemental
appendix S2).23 This classification system uses all positive evidence in study
details to diagnose TBI events more accurately than single indicator systems
(eg, length of posttraumatic amnesia, initial Glasgow Coma Score, length of loss
of consciousness).24


RESULTS


STUDY SELECTION AND CHARACTERISTICS

Of the 408 abstracts identified, 25 were selected for full-text review, and of
those, 13 met inclusion criteria as noted in fig 1. There were no epidemiologic
or population-based studies found. All 13 studies were case studies (table
1).25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37 The mean ± SD age was
22.8±10.5 years, with a range of 11-50 years. Sex distribution leaned heavily
male (77%). The most common place of occurrence was at rock concerts (54%).
These 13 cases were reported in England (3),30,31,37 Germany (2),34,36 India
(2),32,35 Canada (1),25 Belgium (1),26 Sweden (1),27 Italy (1),29 Japan (1),33
and the United States (1).28 The time interval from MAHB to presentation was
variable, including within 24 hours (5),28, 29, 30, 31,35 a few days
(4),32,33,36,37 a few weeks (2),27,34 and up to 3 months (1).26 One case did not
report a time interval.25
 1. Download: Download high-res image (372KB)
 2. Download: Download full-size image

Fig 1. Preferred reporting items for systematic review and meta-analyses flow
chart for the study selection process.

Table 1. Study characteristics

StudyStudy DesignNAgeSexDiagnosisSeverity of TBI*Time Between Injury and 1.
Symptom Onset and 2. Presentation to PhysicianTreatment CourseOutcomeDe Carvalho
et al25CS122FemaleSubdural hematomaDefinite1. Not reported; 2. Not
reported2-burr-hole craniotomySurvivedDe Cauwer et al26CS115MaleSubdural
hematomaDefinite1. Within 24 h; 2. 3 moSurgical drainage; reintervention 40 d
later because of rebleedUneventful recoveryEdvardsson et al27CS120MaleBasilar
artery thrombosisNA1. Not reported; 3 wkIntra-arterial fibrinolytic agent
administrationLocked-in stateEgnor et al28CS115MaleTraumatic true aneurysm of
vertebral artery leading to a hemorrhagic infarctionDefinite1. Immediately; 2. 2
h, 4 wk, 6 wkExcision of aneurysmFull recovery after 1 yGilberti et
al29CS116MaleSubdural hematoma, internal carotid artery dissection leading to a
cerebral ischemic infarctionDefinite1. Within 24 h; 2. Within 24 hConservative
nonsurgical treatmentFull recovery after 90 dJackson et al30CS115MaleInternal
carotid artery dissection leading to both cerebral ischemic and hemorrhagic
infarctionsDefinite1. Within 24 h; 2. 14 hDexamethasone and
mannitolDiedMackenzie et al31CS120MaleSubdural hematomaDefinite1. Within 24 h;
2. Within 24 hDied before treatmentDiedNeyaz et al32CS129MaleSubdural
hematomaDefinite1. Immediately; 2. 3 dConservative nonsurgical treatmentFull
recovery after 1 wkNitta et al33CS124FemaleSubdural hematomaDefinite1. Not
reported; 2. 3 dConservative nonsurgical treatmentFull recovery after 8
moPirayesh Islamian et al34CS150MaleSubdural hematomaDefinite1. 2 wk; 2. 4
wkBurr hole evacuation; subdural drainage for 6 d post operationFull recovery
after 2 moRajasekharan et al35CS135FemaleBasilar artery thrombosis leading to a
brainstem ischemic infarctionNA1. Within 24 hours; 2. Within 24
hoursAnticerebral edema measures; antiplatelet agentsLocked-in stateScheel et
al36CS124MaleSubdural hematomaDefinite1. Not reported; 2. 2 dSurgical
evacuationSurvivedTorrey et al37CS111MaleColloid cyst rupture leading to an
intracerebral hematomaDefinite1. Immediately; 2. 4 d, 17 d, and 18 dGeneral
practitioner prescribed aspirin for headache; general practitioner prescribed
ampicillin for sinus; mother gave aspirin for headacheDiedAbbreviation: CS, case
study; NA, not applicable.

⁎
TBI was classified by the Mayo classification system (insert reference).


RESULTS BY TYPE OF INJURY

All TBIs of case studies were defined as definite TBI. Of these, the most common
mechanism was subdural hematoma. Other mechanisms included internal carotid
artery dissection, basilar artery thrombosis, traumatic true aneurysm, and
intracerebral hematoma.


TBI FROM SUBDURAL HEMATOMA

Eight case studies involving TBI after MAHB were caused from subdural hematomas,
the most prevalent etiology in the current literature.25,26,29,31, 32, 33, 34,36
Gilberti et al29 presented a 16-year-old boy with sudden-onset global diffuse
headache from an internal carotid artery dissection with subsequent temporal and
parietal lobe infarctions and a subdural hematoma from a presumed definite TBI
after head banging at a rock concert the night prior. The patient had a full
recovery after 90 days. Nitta et al33 presented a 24-year-old woman with partial
seizures affecting the right upper and lower limbs from a left-sided subdural
hematoma 3 days after head banging at a punk rock concert. She previously had an
acute left-sided subdural hematoma as a newborn after an accidental fall from a
baby buggy. The patient had a full recovery after 8 months. Mackenzie et al31
presented a 20-year-old man with severe occipital headache and seizures after
head banging to rock music the night prior. An extensive subdural hematoma was
found, with midline shift and cerebellar tonsillar herniation leading to the
death of the patient. Neyaz et al32 presented a 29-year-old male radiology
resident with symptoms of headaches and uneasiness that developed while head
banging at a rock show 3 days previously, without any drug or alcohol
consumption, leading to the discovery of a small left-sided subdural hematoma.
The patient fully recovered after 1 week. De Cauwer et al26 presented a
15-year-old boy with a 3-month history of chronic headaches and new sudden-onset
severe frontal headache with associated photophobia after head banging to music
at a party. A head computed tomography (CT) revealed a chronic right-sided
frontoparietal subdural hematoma with a resultant midline shift to the left. The
patient had an uneventful recovery. Scheel et al36 presented a 24-year-old “hard
rock enthusiast” with severe left-sided headaches 2 days after intense head
banging at a rock concert. A head CT showed a left-sided subdural hemorrhage and
a left temporal pole arachnoid cyst. The patient was discharged from an acute
care hospital. Pirayesh Islamian et al34 presented a 50-year-old man with a
2-week constant worsening global headache, starting after head banging at a
Motörhead concert almost a month previously. He denied substance abuse. A head
CT revealed a right-sided chronic subdural hematoma with midline shift. The
patient had a full recovery after 2 months. De Carvalho et al25 presented a
22-year-old woman with persistent severe headaches with an associated increase
of “head whipping” maneuvers within the last 4 years because of changes in the
style of a popular dance performed on her university dance team. She did not
consume alcohol or smoke. A head CT showed a right-sided chronic subdural
hematoma in the frontal lobe, and she subsequently underwent evacuation. The
patient was discharged from an acute care hospital.


TBI FROM INTERNAL CAROTID ARTERY DISSECTION

Two case studies involving TBI after MAHB were caused from internal carotid
artery dissections.29,30 Jackson et al30 presented a 15-year-old boy with right
hemiparesis, facial weakness, and either right homonymous hemianopia or
right-sided inattention deficit after head banging at a rock concert the
previous evening. He consumed 3 pints of beer during the rock concert. The
postmortem autopsy showed evidence of a dissecting aneurysm of the left internal
carotid artery, presumably caused by the extreme flexion-extension motions of
head banging. The dissection occurred at the bony prominences of the C1 and C2
vertebral levels, where the shearing stresses caused a tear of the internal
carotid artery. He had a definite TBI from a left internal carotid artery
dissection, which led to large cerebral ischemic infarctions, an occipital
hemorrhagic infarction, cerebral edema, and uncal herniation. He subsequently
died 1 week after admission to an acute care hospital. In the case study by
Gilberti et al29 with the subdural hematoma, the sudden-onset global diffuse
headache was caused from an internal carotid artery dissection with subsequent
subdural hematoma. One-month follow-up imaging also revealed right-sided
temporal and parietal lobe infarctions.


TBI FROM BASILAR ARTERY THROMBOSIS

Two case studies involving TBI after MAHB were caused from basilar artery
thrombosis.27,35 Edvardsson et al27 presented a 20-year-old professional
musician who self-proclaimed participation in “intensive head banging,” who
subsequently presented with a 3-week duration of neck pain, headache, and
vertigo. The patient denied substance abuse. After an episode of intermittent
loss of consciousness and several equivocal tests, cerebral digital subtraction
angiography showed basilar artery thrombosis without evident dissection.
Rajasekharan et al35 presented a 35-year-old woman with vomiting, urinary
incontinence, altered sensorium, and tetraplegia, beginning the day after
participating in a religious ritual dance known as devi thullal. This
traditional dance involved fierce head banging for consecutive hours. A brain
magnetic resonance imaging revealed an acute infarction of the ventral pons,
with a subsequent brain magnetic resonance angiogram exposing basilar artery
thrombosis. Both patients survived but remained in locked-in states.27,35


TBI FROM TRAUMATIC TRUE ANEURYSM OF THE VERTEBRAL ARTERY

One case study involving TBI after MAHB was caused from a traumatic true
aneurysm of the cervical vertebral artery.28 Egnor et al28 presented a
15-year-old male drummer with new-onset vertigo, nausea, vomiting, difficulty
with left arm and leg coordination, and slowed speech after fiercely banging his
head and neck while performing in a neighborhood rock band. He had a definite
TBI with a cerebellar hemorrhagic infarction with subsequent discovery of a
traumatic true aneurysm of the cervical vertebral artery, which was found and
treated with emergent neurosurgical excision of the aneurysm. The patient had a
full recovery after 1 year.


TBI FROM INTRACEREBRAL HEMATOMA

One case study involving TBI after MAHB was caused from intracerebral
hematoma.37 Torrey et al37 presented an 11-year-old boy with a severe headache,
nausea, and persistent vomiting, who had participated in head banging to heavy
metal music at a disco party. The patient died after 18 days of failed
treatments for sinus headache before arriving at the hospital. On postmortem
autopsy, it was revealed that a colloid cyst ruptured while head banging,
leading to an intracerebral hematoma, a definite TBI.


DISCUSSION

Each of these 13 case studies presented a patient who experienced a definite TBI
(consistent with moderate-severe TBI) while head banging to music.25, 26, 27,
28, 29, 30, 31, 32, 33, 34, 35, 36, 37 Although no direct trauma at the time of
the event was reported in any of these cases, a traumatic force as a direct
result of extremes in motion was attributed to the concurrent pathophysiological
changes and clinical findings. Hypothesized pathophysiology of these injuries
included dramatic motion leading to sheer forces, further resulting in possible
thrombus formation, which subsequently caused ischemia or infarction in some
cases.27,28,35 The most common clinical presentation observed was a subdural
hematoma. Subdural hematomas are typically caused by a tearing of the bridging
veins resulting in rupture and bleeding into the subdural space.38 In each of
the 8 cases studies, MAHB was thought to cause severe strain on the bridging
veins leading to tears and subsequent hemorrhage.31
In this scoping review, no studies were found reporting MAHB causing mild TBI
(mTBI). Patton et al21 performed an observational study to identify the most
popular head banging technique and the predicted risk of mTBI from head banging.
After observing that the up-down style of head banging was the most popular
among musicians, they began a biomechanical analysis under the assumption that
angular displacement of the head on the C7-T1 axis of rotation followed a
sinusoidal motion pattern in a sagittal plane. Using this assumption, they
constructed head injury criterion and neck injury criterion levels. They then
asked a focus group of 10 musicians to tap the tempo of 11 popular heavy metal
songs to calculate the perceived average tempo of each song. Applying the head
injury criterion and neck injury criterion, cervical range of motion >45°, when
related to the rising tempo, was found to increase the risk of sustaining an
mTBI. When that 146-beats/min tempo was combined with a neck range of motion
>75°, the individual was predicted to sustain an mTBI.
Overall, the evidence was very limited, with only 13 individual case studies
reporting TBI after MAHB. When considering the popularity of hard rock and heavy
metal music around the world, it is unclear whether MAHB is more common than
reflected in our scoping review because of milder symptoms or spontaneously
resolving concussive symptoms that are unreported.31 These injuries may simply
go unreported by rock music enthusiasts; mTBI makes up the majority of TBI
cases.24 A single occurrence of these mild, self-resolving mTBI may be
self-limiting, but compounded by numerous occurrences, these injuries could do
further damage than is currently reported. In addition, there is increasing
evidence of a cumulative effect associated with repeated brain injuries,
including repetitive subconcussive TBI, which can result in an increased risk of
long-term sequelae.39,40 Given the repetitive nature of MAHB, it is possible
that MAHB may be associated with a similar risk.21 Further research is needed to
understand this risk.
In addition to TBI, traumatic cervical injuries were also noted in the
literature. While outside the scope of this review, it is important to consider
cervical spinal cord injury as another possible risk factor after MAHB.41


FUTURE DIRECTIONS

Future studies are necessary to further stratify TBI symptom severity, incidence
of symptoms, and possible long-term sequelae of MAHB and to understand whether
multiple subconcussive events associated with MAHB affects patient morbidity.
Future retrospective cohort studies could also address the incidence of other
non-TBI MAHB injuries, such as cervical injuries including whiplash,
radiculopathy, vertebral fracture, and spinal cord injury. There is a scant
amount of current research on this topic. While it is plausible that the
incidence of TBI, and mTBI in particular, is higher than reported in the
literature after MAHB, further research is needed to understand the public
health implications. Potential considerations for future research include
qualitative studies and survey methodology of concert goers to assess whether
individuals describe symptoms of mild or moderate-severe TBI, observe others
with these symptoms, and understand the relative frequency of co-occurring
behaviors such as substance abuse or moshing.


STUDY LIMITATIONS

This scoping review has its limitations. Our overall summary of the public
health implications of MAHB was limited by very few case reports in the
literature with an overall very small sample size (N=13). Our search included
only studies where the mechanism of injury for TBI was MAHB, and mixed-etiology
studies (such as general epidemiologic studies evaluating multiple etiology of
TBI) were excluded, making it possible for occurrences of TBI by MAHB within
such studies to be missed. For most public health problems, there is clear
exposure data. While concerts and associated MAHB are generally a common
phenomenon around the world, there is no objective data on the prevalence of
concerts or the prevalence of engaging in dangerous behaviors, such as MAHB, at
concerts, which makes it challenging to assess the incidence of MAHB. The “dose
response” was unattainable from the case reports in that neither intensity of
head banging nor duration of MAHB was described in any case reports, and this
requires further research to understand. Additionally, a majority of the
authors26,28,29,31,33,35, 36, 37 did not report concurrent risky behavior, such
as drug or alcohol consumption, as potential confounding factors. Although we
cannot be fully certain that MAHB was the cause, each case was described by
medical professionals in a hospital setting who ultimately felt that the primary
etiology of the injury was MAHB. Lastly, information regarding potential
comorbidities that could predispose to injury was missing in all but 1 study.30


CONCLUSIONS

Despite how common MAHB is in popular culture, there are only a few isolated
case reports of moderate-severe TBI reported in the literature. The discussed
self-inflicted TBI are thought to be caused by the harsh repetitive rhythmic
motions; however, there are still many unknowns when it comes to this cause of
TBI. Additional research is needed to understand whether MAHB is associated with
mTBI to guide clinical and preventative strategies further.


APPENDIX. SUPPLEMENTARY MATERIALS

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CITED BY (0)


Presented as a poster to the International Society of Physical and
Rehabilitation Medicine World Congress and Association of Academic Physiatrists,
March, 3, 2020, Orlando, FL.
Disclosures: none
© 2022 The Authors. Published by Elsevier Inc. on behalf of American Congress of
Rehabilitation Medicine.


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