Seizure 42 (2016) 44–48Contents lists available at ScienceDirect Seizure journal homepage: www.else vie r .com/ locat e/y seiz Ictal kissing: Electroclinical features of an unusual ictal phenomenon$ Çigdem Özkaraa,*, Emine Taşkıranb, I_ rem Yıldırım c Çarpraz , Erhan c Bilir , Aylin Bican Demird, I_ brahim Borad, I_brahim Aydogdue, Şakir Delila, Francine Chassouxf aDepartment of Neurology, Cerrahpaşa Medical Faculty, Istanbul University, Istanbul, Turkey bDepartment of Neurosurgery, Cerrahpaşa Medical Faculty, Istanbul University, Istanbul, Turkey cDepartment of Neurology, Medical Faculty, Gazi University, Ankara, Turkey dDepartment of Neurology, Medical  Faculty, Uludag University, Bursa, Turkey eDepartment of Neurology, Medical Faculty, Ege University, Izmir, Turkey f Centre Hospitalier Sainte Anne, Paris, France A R T I C L E I N F O A B S T R A C T Article history: Purpose: The study aimed to describe the electroclinical features of ictal kissing, an unusual behavior that Received 6 June 2016 may occur during focal seizures. Received in revised form 10 September 2016 Method: Twenty-five patients collected from four epilepsy centers and previously published reports were Accepted 23 September 2016 reviewed for their demographic, clinical, and electrophysiological features. Results: Sixteen of 25 patients were female. The mean age was 32.9 years (9.9–51 years) and the average Keywords: age at seizure onset was 14.5 years. All seizures were localized to the temporal lobe (TL) and lateralized to Ictal kissing right side in 17 patients, left side in 2 patients, and unclear in 6 patients. A total of 55 ictal video Temporal lobe Limbic sytem electroencephalograms (EEGs) were analyzed. There were other symptoms such as speaking, spitting, Epilepsy hugging, and oral and upper-extremity automatisms along with different types of ictal kissing behavior Emotion during the seizures. The median duration of all seizures was 106.7  73.73 s. Kissing occurred at a median Automatism time of 71 s (1–95 s) after the onset of seizure, and ictal epileptiform discharges usually involved TL during kissing episode. Conclusion: Ictal kissing is mainly associated with right TL and female gender, although association with left TL may also occurs, possibly related to the circuits involving temporo-insular structures. ã 2016 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.1. Introduction Automatisms are more or less coordinated, repetitive, motor activities that occur when cognition is usually impaired. They often resemble a voluntary movement and may consist of an inappro- priate continuation of ongoing preictal motor activity. The patient usually becomes amnesic for these events [1]. Automatisms are categorized as oroalimentary, mimetic, manual or pedal, gestural, hyperkinetic, hypokinetic, dysphasic, dyspraxic, gelastic, dacrystic, vocal, verbal, spontaneous and interactive in the International League Against Epilepsy (ILAE) report of seizure semiology [1]. Some automatisms have lateralizing and localizing value [2] but$ This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. * Corresponding author at: Istanbul University, Cerrahpasa Faculty of Medicine, Department of Neurology, Fatih, Istanbul, Turkey. Fax: +90 212 633 01 76. E-mail addresses: cigdem.ozkara@gmail.com, cigdemoz@istanbul.edu.tr (Ç. Özkara). http://dx.doi.org/10.1016/j.seizure.2016.09.013 1059-1311/ã 2016 British Epilepsy Association. Published by Elsevier Ltd. All rights restheir mechanisms and related inner driving sources are still need to be investigated. Ictal kissing is a rare automatism observed during focal seizures. Only nine patients have been reported previously in the literature. The seizures were localized mainly to TL in all and lateralized to right hemisphere in eight of them [2–7]. Although the clinical significance remains unclear, the occurrence of ictal kissing was found to be associated with common psychological features [7]. We report 16 additional cases from different centers with ictal kissing and reviewed the previously reported nine (4 from our center) cases. In 15 of them, we were able to analyze the semiologic and electroencephalographic features associated with ictal kissing automatism. 2. Methods Medical records of 20 patients with documented ictal kissing were provided from four epilepsy centers. Demographic, clinical, video EEG, and imaging data, if available, were analyzed anderved. C. Özkara et al. / Seizure 42 (2016) 44–48 45reviewed, including the previously reported 9 patients in the literature [2–7]. All patients were resistant to antiepileptic drug medication and subjected to pre-surgical evaluation, including inter-ictal and ictal video EEG, magnetic resonance (MR) imaging, and FDG-PET in 15 of them. Ictal video EEG recordings, which were available from 15 patients, were analyzed considering detailed semiologic and electroencephalographic characteristics such as total seizure duration, timing of kissing automatism, and other features of the seizures. 3. Results The demographic and clinical data of 25 patients are presented in Table 1. Sixty-four percent of the patients were female. The mean age was 32.9 years (9.9–51 years). The average age at seizure onset was 14.5 years (5–23 years). All patients had focal seizures, with or without secondary generalization. Twenty-two patients were on at least one antiepileptic drug; three patients did not take any drug because they were seizure free. Past history was remarkable with febrile seizures in 7, viral meningitis in 1, neonatal asphyxia in 2, unremarkable or unknown in 16 patients. Neuropsychological evaluation which was available in 13 patients revealed material specific memory deficits in 8 (P1, 2, 4, 10, 11, 12, 13, 19, 20), attention deficits in 4 (P3,11,12,13) and visuospatial deficits in 2 patients (P14, 16) and normal IQ in all. Psychiatric interview disclosed traumatic childhood and unfulfilled affective needs with major depression in 4 patients who were published separately (P1, 2, 3, 4) [7]. Depression was also diagnosed in 1 more patient (P19). However further information related to their psychosocial status cannot be obtained in other patients as they were recruited from different centers. Nine patients out of 25 underwent surgery, all but one after non-invasive investigations (P1,10,12,14,15,17, 21, 24 and 25). One of these surgical patients, who was from Paris, underwent stereoelectroencephalography (SEEG) prior to surgery. Eight patients were seizure free since then. Three patients refused surgery and five were on the waiting list. Fifty-five ictal video EEGs obtained from 15 patients were analyzed. Ictal kissing was observed in 28 events (50.9%) where TL was involved at the time of kissing in all of them. The seizure onset was located in the TL in 13 patients (10 on the right side, 3 on the left) and was not determined in two patients because of movement artifacts and hypermotor behavior. Although the majority of the patients had right temporal epileptiform discharges on inter-ictal EEG, they were bilateral in four with a prominence of left TL in two patients (P5, 7). Both inter- ictal and ictal EEG demonstrated left-sided abnormality in two patients (P4, 15). SEEG investigation was recorded in only one patient (P10), who revealed the involvement of temporal pole and lateral temporal neocortex with propagation to the frontal lobe. Unfortunately, kissing automatism was not observed during this intracranial recording. Subdural recording was performed in P25, who was one of the previously reported cases. It demonstrated epileptiform discharges on the right frontal lobe during kissing. The hand dominance was right in 16 right temporal lobe epilepsy (TLE) patients, left in 2 right TLE (P2, 10), left hemispheric dominance in one (P10) of those was demonstrated by the Wada test, and left in only one left TLE patient (P4). The hand dominance was not determined in one patient. 3.1. Semiologic features of seizures The median duration of all seizures was 76.5 s (5–283 s). Kissing occurred after a median time of 71 s (1–195 s) of seizure onset and was usually preceded by other behaviors such as ictal speech and oral and upper-extremity automatisms. Four patients presentedictal kissing within the first 35 s (5–33 s) after the onset while it occurred after 35 s in the rest of the patients. Consciousness was partially preserved in 16 seizures arising from right but not left TL. Aura was described in 13 of 20 patients. Epigastric sensation was the most frequent aura, followed by dreamy state, experiential visual sensations, tinnitus, goose bumps, nausea, smelling unpleasant odors, feelings of confusion, fear, strange sensation, headache, staggers, and anxiety. The kissing behavior differed from one patient to another. It was not stereotypical even in the same patient. Six patients blew kisses to the air during the seizure. Nearly half of the patients kissed the hands or arm, one third of them kissed the cheek of the individuals around, and one young woman engaged compulsively in lip kissing (P4), which was accompanied by other behaviors such as water drinking, speaking, and hand automatisms. This interesting patient had left-sided hippocampal sclerosis (HS) on MRI with left-sided ictal and inter-ictal epileptiform activity on EEG. Moreover patients did not show any mirthful emotion but either sadness or neutral during kissing behavior. Seizures were always diurnal in all 20 patients except one (P8) having seizures soon after she fell asleep, which were character- ized by staring, lip smacking, and blowing kisses with incompre- hensible speech. She had normal MRI and right-sided epileptiform activity on EEG. 3.2. Imaging MRI scan revealed lesions within the TL in 15 including mesial temporal sclerosis (MTS) in 14 (11 right, 2 left, 1 bilateral), arterio- venous malformation (AVM) in 1. Other observed lesions included cortical dysplasia, posterior cerebral artery (PCA) infarct, AVM, and frontal cortical and subcortical gliosis where it was normal in seven (Table 1). MRI was normal, but histopathology was cortical dysplasia type IIa in one (P21). FDG-PET was available in 15 patients, which showed hypo- metabolism at TL in 14 (left in 2, right in 12) and was normal in one (Table 1). In all patients with abnormal imaging, inter-ictal or ictal EEG abnormalities correlated with the lesional areas. 4. Discussion Careful analysis of ictal semiology is crucial for delineation of epileptogenic zone. In this context, each ictal phenomenon reflects the involvement of cortical regions by the epileptic discharge from onset to propagation and is investigated in terms of lateralizing and localizing importance. Several semiologic features are described and listed by the ILAE terminology task force, such as motor, nonmotor, and autonomic behaviors [1]. Automatisms are classified as motor symptoms and defined as a more or less coordinated, repetitive motor activity usually occurring when cognition is impaired; the subject does not remember them afterward. The automatisms often resemble a voluntary movement and may consist of inappropriate continuation of ongoing preictal motor activity in the same report [1]. There is a variety of automatisms, such as oral, mimetic, manual, pedal, gesture, and other presentations. Kissing was not mentioned in this report [1], although it may partly fit oral automatisms when lip smacking, lip pursing, chewing, licking, tooth grinding, and swallowing were listed in this group. This may be due to its rare occurrence, as was reflected by only nine patients reported in the literature, four of which were those from 11 patients belonging to our center [2–7]. The mechanism of automatisms has three main speculative explanations. They may emerge as a reaction to internal stimuli, as an activation of a specific motor program with cortical stimulation, or as the removal of inhibitor control as a release phenomenon [8]. 46 C. Özkara et al. / Seizure 42 (2016) 44–48Table 1 Electroclinical and imaging features of patients with ictal kissing automatism. Patients Gender/ Age at Handed MRI PET hypo- Inter-ictal EEG Ictal EEG Aura Associated ictal behaviors age onset metabolism epileptiform (yrs) (yrs) activity P1,FS* F/28 16 R R MTS None R> LT R FT, spreading to bil FT Epigastric Religious speech, oral automatism, ictal water drinking, kissing sensation technician’s hand, blowing kisses P2,NM* F/35 17 L R MTS R T R T R> LT Feeling dreamlike Oroalimentary automatism, raising L hand, kissing cheek and in another place P3,CG* M/26 16 R normal RT RT R> LT Tinnitus in the R Oroalimentary automatism, speech, blowing kisses, coughing ear, goose bumps P4,NI* F/29 5 L L MTS LT LT LT Smelling, bad Speech, L-hand automatism, water drinking, R-hand dystonia, kisses odors from lip P5,NG F/20 9 R Normal R T L >RT Nonlateralizing and None Hypermotor automatisms, L-hand dystonic posture, coughing, kisses localizing ictal onset late from hand, religious speech, crying built up at LT P6,GO F/51 22 R R MTS R T R T R FT Palpitation, Oral automatism, bil upper-extremity automatism, kissing from cheek paraphasia P7,MR F/29 18 R Normal None Bil ant T None None Hand automatism, water drinking, hugging and kissing from cheek P8,MS F/24 23 R Normal None R ant T None None Oroalimentary automatism, incomprehensible speech, blowing kisses P9,BA1 M/46 12 R L T and O gliosis None L OT None Headache, grayout Hand automatism, blowing kisses (PCA infarct) P10,SF M/41 10 L R MTS R T- R T R TF Epigastric Oro-alimentary automatism,whistle, gargle, sucking, foreign-language F_Insular sensation, nausea ictal speech, dance-like movements, pedaling, kissing from hand, spitting P11,FEO M/31 5 R Normal R T R T R T None Oroalimentary automatism, religious speech, utterance of noises, kissing from hand P12,GÖ F/32 12 R R MTS and O R T R T R T None Fondling on arm, kissing from cheek and arm Ulegyria P13,AD M/25 10 R R MTS R T R T R T Confusion feeling Right-hand and oral automatism, groaning, kissing from hand, hugging P14,ZD F/23 17 R R MTS R T R T R T Strange sensation Staring, kissing from hand, R-hand automatism, L-arm dystonia, religious speech P15,KT M/20 9 R L MTS L T L T L T Epigastric Staring, kissing from hand, spitting, vomiting, incomprehensible sensation speech P16,FG F/22 9 R P neuronal R T R T R T, spreading to all R Anxiety Screaming, fear, hypermotor behavior, oral and R-hand automatism, migration anomaly hemisphere kissing from cheek P17,SSK F/41 9 R R MTS None R T R T None Staring, confusion, kissing from cheek, speech, R-hand automatism, L- arm dystonia P18,MG M/44 12 Unknown Normal Unavailable R > LT None None Aggression, hypermotor behaviors, blowing kisses, spitting P19, BA2 F/32 5 R Bil MTS Normal L T L >RT Fear Oral and hand automatism, blowing kisses P20, IK M/37 21 R L T AVM None None None Nausea, dry Speech, blowing kisses, bottom lip mouth, taste P21. Rashid F/39 33 R Normal R T R T R T Nausea Tingling arms and legs, oral automatism, blowing kisses, kissing from et al. [5] hand P22. F/46 26 R R MTS None SW, R T R T, spreading to the R > L F None Whimpering, oral automatism, fumbling with R hand, L-arm dystonic Rashid posturing, hugging, kissing from cheek et al. [5] P23. F/48 18 R R MTS None SW, R > LT R FT, spreading to bil FT Warm, rising staring, repetitive leg movements, fumbling R hand, oral automatism, Rashid sensation blowing kisses et al. [5] P24. Mikati M/24 10 R R MTS None Unknown R T, in some seizures evolving None Altered consciousness, spitting, repetitive hugging and affective et al. [4] to bil FT kissing, head and eye deviation to the L P25. F/29 19 R R F small cortical R T SW, R T R FT None R-hand automatism, L-arm dystonic posturing, lip smacking, hugging Alsemari and subcortical and kissing her relative and/or attendant nurse with emotional et al. [6] lesions gestures Abbreviations: M—male; F—female; yrs—years; R—right; L—left; MTS—mesiotemporal sclerosis; T—temporal; OT—occipitotemporal; TF—temporofrontal; FT—frontotemporal; AVM—arteriovenous malformation; bil—bilateral. C. Özkara et al. / Seizure 42 (2016) 44–48 47Swallowing due to excessive salivation may be an example for the first hypothesis. The second mechanism refers to cortical activa- tion of functionally localized behavior such as simple motor movements usually when the patient is awake. This mechanism may partly explain the emergence of automatisms, although some case reports describe electrical cortical stimulation of insular operculum, hippocampus, amygdala, and mesial frontal lobe– induced oral automatisms [8,9] and stimulation of hypothalamic hamartomas-induced laughing and crying [10]. By definition, more complex, semi-purposeful automatic movements are seen when the cognition is impaired, and such ictal events including kissing automatism has never been reported to be induced by cortical stimulation. The third mechanism proposing the temporary loss of neocortical control leading to release phenomena may be supported by the presence of similar stereotypic behavior in other neurological disorders such as autism, dementia, and schizophre- nia [11,12]. Moreover a dysmnesic phenomena, such as a recurrence of a scene from the past with a strong emotional connotation may also be suggested as a fourth mechanism (P10). Epileptic seizures may cause not only excitation but also inhibition of ongoing neuronal activity, leading to behavioral dysfunction or disinhibition. Central pattern generators (CPGs) located in the brain stem and spinal cord are essential for survival, such as feeding-, locomotion-, and/or reproduction-inducing behavior or emotions, along with innate motor patterns [13]. Kissing behavior may emerge after loss of inhibition on CPGs as an innate behavior pattern during an ictal event; originate from daily life activities; be inducement of an emotional connection, including demonstration of love for a special person; or be a sign of deferential behavior. Thus, the patients may share similar complex emotional backgrounds. From this perspective, ictal kissing may also be the result of reaction to an internal stimulus occurring as a specific pattern of behavior in relation to loss of conscious control or cortical inhibition. From a psychological perspective, ictal kissing behavior may be the expression of many kinds of feelings, such as love, respect, and kindness. Except for some African tribes who consider kissing a disgusting gesture, kissing in almost all cultures is a common social interaction starting in early childhood [14]. It may be the reflection of love and sexual desires with emotional bond or of the respect for the person whose hand is kissed. Kissing stimulates the secretion of endorphins during breast feeding when an innate infant behavior resembling kissing induces oxytocin, a facilitator to pair bonding and parental care [15]. Erotic kissing may originate from behaviors related to feeding offspring or in birds feeding their partners before mating. This behavior also includes feelings of safety and trust, which are important features of the pair bond between mother and child [14]. Our psychoanalytic investigation of a small group of patients with ictal kissing revealed traumatic childhood histories and intense unfulfilled affective needs with major depression in all. In that report we proposed that the past negative experiences and need for love may manifest itself through the content of seizures as a desire to kiss or to be kissed [7]. Kissing is an emotional behavior. The limbic system which is composed of the amygdala, hippocampus, parts of the thalamus, and other structures (mammillary body, cingulate gyrus, fornix) has a mojor role in producing emotion. It is a kind of “primitive core” of the brain strongly associated with emotion. In lower animals, the limbic system helps organize basic survival responses, such a feeding, fighting, or reproduction where an obvious link to emotion remains in humans [16]. Emotional behaviors may change according to the gender, which is attributed to anatomo-functional differences in the mesial temporal region [17]. Expression patterns of some behaviors in male or female could be related to the their various unresolved stages of a love relationship and cultural differences [18]. Althoughfemales consisted of the majority of the patients, there was no association between type of kissing pattern and gender in this study. Overall, we observed kissing from the hand or arm (40%), from the cheek (30%), and from the lips and blowing kisses (30%) without a specific gender predilection. Interestingly, the kissing behaviors were not stereotypical even in the same patient, which may be due to distraction by the environment. Therefore, an association between gender and variable kissing patterns in terms of anatomo-functional link remains speculative. Kissing automatism is known to be rare but it is not possible to estimate the real incidence in this group of patients as all of them were from a selected population of surgical candidates which is the major weakness of this study. Moreover, the wide difference at the time of occurrence of kissing after a seizure onset, duration of seizures, variety of phenomenology even in a single patient, various underlying etiology, epileptogenic zone extending beyond TL even extra temporal localization implies that the kissing phenomenon is something reflecting a wide network activation by seizure discharge propagation and thus TL involvement rather than the being origin of it. Moreover, “tuning” of the emotional system pre-ictally can be different from one moment to another which is modulated by the limbic system and its connections, the pivotal epileptogenic zone responsible for emotion related ictal signs as mentioned above. This may explain the variability of the occurrence within the seizures and among the patients as well. The epileptogenic zone was demonstrated to be related to right/ language nondominant TL inprevious reports [3–6] except one [7]. In this series of 25 patients (including the previously reported 5 patients) it was related to the right side in 16, left side in 4, and unclear in 5 patients due to normal or bilateral MRI and EEG findings. Rashid et al. implied that the importance of the preservation of responsiveness and ictal speech were necessary for ictal kissing to interact sufficiently with the environment [5]; however, the epileptogenic zone in two of our patients was on the dominant TL without speech and responsiveness during the seizure. Lateralization of brain functions was defined for language- related areas and for different functions, including emotion processing. The right hemisphere was postulated to be responsible for emotional processing [19], whereas valence theory proposes that lateralization depends on the type of emotion; in this view, happiness and affiliated emotions would be processed predomi- nantly by the left hemisphere, and sadness by the right hemisphere [20]. A majority of patients with ictal kissing have shown right- hemisphere involvement without showing and happiness, which may accord with both hypothesis. Not handedness but the type of brain structures [21] was shown to be responsible in emotional processing, which may explain the occurrence of ictal kissing in patients with left-handed or left-hemispheric involvement. All available video EEG recordings with kissing revealed ictal discharges related to TL even in the patient with parietal cortical malformation who had discharges propagating to right TL at early phase. Three previously presented patients were also reported to have right-TL involvement [5], whereas one with a right–frontal lobe lesionwho was explored with subdural electrodes demonstrated the spread to frontal from right mesial temporal who underwent resection of both frontal lesion and and temporal lobectomy with amigdalohippocampectomy [6]. One case with ictal kissing and spitting precipitated by specific patterns was reported to have right mesial temporal lesion and low-grade astrocytoma and remained seizure free after surgery [4]. Temporal lobes were bilaterally involved in three patients (P2, 3,19). There may be some relation to Klüver–Bucy syndrome, which is presented by hyperorality and inappropriate sexual behaviors like the previously reported patient with ictal kissing [5] and ictal hyperorality [22]. The fact that the majority of cases showed one-sided involvement depending on this rare syndrome will not be valid for all patients. 48 C. Özkara et al. / Seizure 42 (2016) 44–48Thus, whether unilateral or bilateral, the majority of patients presenting with ictal kissing in this study correlated with mainly TL involvement according to the scalp EEG, which fails to show the involvement of deep structures such as insula, although SEEG investigation in one patient revealed insula to be included in the epileptogenic area. However, involvement of the insular cortex in almost all subgroups of TL epilepsies which was demonstrated in PET studies [23] is well-known fact, which contributes the mechanistic explanation of kissing automatism. Several studies demonstrated the prominent role of right anterior insula, a phylogeneticallyarchaic allocortical structure, inprocessing emotion regardless of handedness and its significance as the principal structure of the cranial nerve system responsible for sentience and self-consciousness [24–26], right hemispheric activa- tion dominanceduringsadness,andcontralateraldominancerelated to happiness. It is not easy to consider kissing as a negative emotion; however, ictal discharges may have both inhibitory and excitatory effects. However, none of the patients were joyful but either sad or neutral. Therefore, kissing may well be the resultof activation of right hemisphere with negative emotions. Responsiveness may be preserved in patients when the nondominant hemisphere is involved during the seizure. However, they continue to have different types of automatisms, and they can respond to the examiner without being able to recall the event at all. One can argue whether the consciousness is impaired during these seizures. Our understanding and assessment of ictal consciousness, focusing on both subjective and behavioral aspects of seizures, need to be considered here. There have been suggestions that both the internal and external milieu-the former related to the phenomenal qualiaof experience, the latterrelatedtobehavior-mustbetaken into account for a better understanding of altered states of consciousness in epilepsy. A bidimensional model, in which any manifestation of conscious experience can be plotted according to the level and contents of consciousness, was proposed when the level axis measures the degree of alertness/arousal, whereas the contents axis measures the vividness of specific experiential phenomena reported by the patient. In a recent paper it was argued that certain seizure types might require more rigorous conceptual models for their characterization, a three-dimensional model that includes a further dimension related to the self, in addition to those of level and contents [27]. A complex behavior such as kissing occurring while the awareness and partial content is preserved during a seizure can also beexplainedby the impactofa self-componentofconsciousness according to the new proposal. And while the anterior-dorsal insula wasregardedasthefinal stageofahierarchical processing,startingin the posterior insula with pure sensory information, then integrating emotional and cognitive valuation, ending in the anterior-dorsal insular region with a full representation of a “sentient self,” the sine qua non of self- awareness [28], invasion of insula with seizure discharge may well responsible of disruption of self component of consciousness as proposed. 5. Conclusion Kissing automatism is a complex and rare ictal phenomenon, associated with TLE but in itself reflecting the activation and/or inhibition of networks involved with rather basic innate behavioral patterns more than strict TLE pathology. It is correlated mainly with right-TLE with a predilection in females. However, involve- ment of dominant TL and male gender is rare but also possible. Although the precise mechanism remains obscure, it may occur as a release or dysmnestic phenomenon rather than a cortical stimulation, possibly due to firing of extensive circuits centered at the insular and TL or as the result of internal stimulation that facilitates CPG with loss of conscious control.Conflict of interest statement None of the authors has any conflict of interest to disclose. References [1] Blume WT, Lüders HO, Mizrahi E, Tassinari C, van Emde Boas W, Engel Jr. J. 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