Using the S9 Autoset w/ Centrals... Suggestions appreciated

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
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Arizona-Willie
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Re: Using the S9 Autoset w/ Centrals... Suggestions appreciated

Post by Arizona-Willie » Mon Mar 08, 2010 5:35 pm

Thanks Dreamdiver, I just made those changes.

Also, I measured my Climateline hose out of curiousity -- 77 inches tip to tip.

6' 5" ... 8 foot would be nice. Mebbe in a few months they will make a longer one if they get lots of feedback.

I'm used to using a short hose with a swivel between my regular hose and the mask which makes turning over etc. easier.

Don't think I can use that anymore because of the sensor in the Climateline hose.
It would be close enough to the mask to work probably.

I'm doing the same thing you did. Set it for CPAP at my regular pressure to compare.
But my readings vary all over the place with the old S8. One day 1.7 next day maybe 7.3 -- just never know.

How do you know your apneas are central? The color of the little square? I've not seen anything telling about different colors and what they mean.

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Re: Using the S9 Autoset w/ Centrals... Suggestions appreciated

Post by snnnark » Mon Mar 08, 2010 5:58 pm

What I meant to say was it would be great if the CMS range of oximeters could connect to the various machines! Seems a lot of us have them.

I'm in a similar boat to you regards the centrals although mine are caused by bradycardia. I've been experimenting with rebreathing tubes and while it definitely reduces the AHI, I still feel like crap the next day! Seems the SV is the way to go but that's not going to happen for me... at least not in this lifetime!

I wonder, do you do a lot of diving? (its late and i'm not going to search through your posts ) If you do, I'm speculating that the scuba gases may mess up your co2 levels but that's pure conjecture on my part!!

Have a good one

Deon

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Re: Using the S9 Autoset w/ Centrals... Suggestions appreciated

Post by DreamOn » Mon Mar 08, 2010 6:09 pm

dsm wrote:While you have this thread going so well - here is a link to the ResScan clinician's manual.

It may be of interest to some readers. It is the 3.2 guide *but* the overall way it works is the same as 3.10.
I'll post a 3.10 manual when I can get one.
Here's a link to the 57-page ResScan 3.10 Clinical Guide, posted several weeks ago by Uncle_Bob: http://tinyurl.com/ya4h4hg.

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dsm
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Re: Using the S9 Autoset w/ Centrals... Suggestions appreciated

Post by dsm » Mon Mar 08, 2010 6:19 pm

DreamOn wrote:
dsm wrote:While you have this thread going so well - here is a link to the ResScan clinician's manual.

It may be of interest to some readers. It is the 3.2 guide *but* the overall way it works is the same as 3.10.
I'll post a 3.10 manual when I can get one.
Here's a link to the 57-page ResScan 3.10 Clinical Guide, posted several weeks ago by Uncle_Bob: http://tinyurl.com/ya4h4hg.
DreamOn - thanks - I thought thats what I had but when I went to the repository only found the older one.
This one now goes in with the other thanks (and also thanks to Uncle Bob)

Just need that clin manual for the s9 now

Cheers

DSM
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Re: Using the S9 Autoset w/ Centrals... Suggestions appreciated

Post by DreamDiver » Mon Mar 08, 2010 6:24 pm

I thought I'd posted something this closeup before, but I can't seem to find it.
You want high-resolution? Look at this:
Image
These images are very large - sorry - if you can't see it here, try this:
http://www.montfordhouse.com/cpap/s9/pa ... loseup.gif

Arizona-Willie - See the little "42" in the graphic? It's next to an apnea. The key to the side shows this color as central. All of mine are this color. Hence - central apneas for me.

snnnark - I've never been in scuba gear, but I do love the ocean. The pen name is more about the juxtaposition of 'diving' into 'dreams'. It seemed appropriate when I signed up for forum membership. I wondered a while back if CO2 rebreathing might be an answer for myself. It seems a little scary to me - sort of on the edge of asphyxiation. I know some on this forum have created their own CO2-slow-dissipation masks. I don't know enough about it to be knowledgeable. It's good to get the feedback that it still gives you a headache.

If I have bradycardia, it may stem from too many aliens beaming me up to their motherships for expert consultation. Contrary to popular belief, alien probes are a myth. But they like scuba diving.

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Re: Using the S9 Autoset w/ Centrals... Suggestions appreciated

Post by dsm » Mon Mar 08, 2010 6:56 pm

DreamDiver,

Re PaCO2 levels for you, from what I am seeing in the charts, you are showing more of a case of repeated patterns of too little PaCO2 hence the repeated cycles where your respiration drops to allow the PaCO2 levels to rise which are then picked up by the CO2 chemoreceptors in your brain (this link is a quick grab that mentions the process http://www.ncbi.nlm.nih.gov/pubmed/10501632 There are probably better links ).

From my very limited understanding (being a non medical person) there are multiple reasons why such a PB pattern as your are showing, can emerge.

1) Being CSR from heart problems, where the heart is weak & slow to pump the blood to the brain so there is a lag in the PaCO2 level being picked up by the appropriate chemoreceptors which then over compensate when they signal the next bout of hyperventilation

2) Some other non CSR related imbalance (high altitude) or damage to the chemoreceptors ability to respond to the fluctuating PaCO2 levels. Allowing that there appear to be multiple places in the body where PaCO2 abnormalities are detected.
Some links that may help ...

http://www.springerlink.com/content/2dw41wn9q6y9lu9j/

http://jp.physoc.org/content/560/1/1.full.pdf

DSM

(hope this makes sense - is a complicated area)
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Re: Using the S9 Autoset w/ Centrals... Suggestions appreciated

Post by -SWS » Mon Mar 08, 2010 8:20 pm

Image
DD, I don't think those flat spots are what get scored as hypopneas since they appear shorter than 10 seconds. Rather, I think they are just treated as post-expiratory pauses because of their short duration.

However, there are several consecutive low-amplitude volumes----just to the left of that first circle----that the machine might have scored as a single hypopnea. Recall that a hypopnea can actually take several breaths---and it is an amplitude reduction compared to a running baseline of previous breaths. By contrast to that initial hypopnea, the second set of reduced amplitudes are perhaps: 1) a little higher at the peaks, 2) peak-compared against a slightly lower running amplitude baseline, and/or 3) might not hit the necessary 10-second amplitude-reduction criterion to qualify.

Does the data set per chance tell you the duration of the hypopnea on the left? If so, you can probably figure out how many reduced inspiratory breaths were included. According to eyeball, each inspiratory peak seems on the order of 5 second periods/breath-rate (visually normalize flow periods w/in a 1-minute epoch then divide 60 by total periods----thus 60 divided by a rate of 12 or 13 normalized breaths = about 5 seconds per breath).
DreamDiver wrote:My apneas seem to cluster primarily after the bathroom break as I'm trying to fall back to sleep. I seem to do pretty darned well for the first part of the night.
I agree that you seem to show a slight tendency for post-bathroom/awakening central periodicity there. That's not to say you have a periodic breathing problem.

That said, it might be interesting to run an experiment with fluid intake during the day. If it were me, I'd try a few days in which I completely eliminated late-day fluid intake---trying to avoid bathroom breaks. If I succeeded avoiding those bathroom breaks, then I'd compare: 1) periodicity patterns in the data set, and ESPECIALLY 2) how I seemed to sleep that night and subjectively felt during the following days. If there was a marked improvement, then I'd consider changing fluid intake and/or asking the doctor for an ASV trial based on the data and subjective results of that experiment.

Good luck, DD! Thanks for sharing those most interesting graphs!

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Re: Using the S9 Autoset w/ Centrals... Suggestions appreciated

Post by dsm » Mon Mar 08, 2010 9:33 pm

DreamDiver wrote:I thought I'd posted something this closeup before, but I can't seem to find it.
You want high-resolution? Look at this:
<snip>

Arizona-Willie - See the little "42" in the graphic? It's next to an apnea. The key to the side shows this color as central. All of mine are this color. Hence - central apneas for me.

snnnark - I've never been in scuba gear, but I do love the ocean. The pen name is more about the juxtaposition of 'diving' into 'dreams'. It seemed appropriate when I signed up for forum membership. I wondered a while back if CO2 rebreathing might be an answer for myself. It seems a little scary to me - sort of on the edge of asphyxiation. I know some on this forum have created their own CO2-slow-dissipation masks. I don't know enough about it to be knowledgeable. It's good to get the feedback that it still gives you a headache.

If I have bradycardia, it may stem from too many aliens beaming me up to their motherships for expert consultation. Contrary to popular belief, alien probes are a myth. But they like scuba diving.
DreamDiver,

That is interesting in that the FOT burst appears to remain on for the whole 42 secs - no stopping after 10 secs & repeating. Docs I read about it talk of a 10 secs burst. Maybe it only does the 10 secs burst if the apnea is OSA but when it is deemed CA it runs until the arousal that ends the CA.

DSM
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Re: Question for Dreamdiver and some remarks about UPS.

Post by Uncle_Bob » Mon Mar 08, 2010 9:53 pm

Arizona-Willie wrote:Dreamdiver, on the setting for Sleep Quality ... did you have to set it to ON to get more data or did you leave it on usage?
What is that Sleep Quality thing anyway?

My unit FINALLY arrived after 5 days of waiting for UPS to bring it. It was in town at 5 pm Friday night and no excuse for not bringing it Saturday.
I'm very disappointed in UPS. The tracking quit at 12:40 am Saturday morning with no further updates over the weekend.
Then, when the guy brought it, he just set it in front of the door and rang the doorbell.
By the time my owner got to the door he was gone.
We didn't have to sign for it or anything.

When FedEx brings a high value package it comes in a special small van and you have to sign for it.
This guy just flopped over $700 down and walked away.
What if we hadn't been home? Just because there were vehicles in the drive doesn't mean we are home.

UPS is gonna get a phone call I think ... not that it will do any good.

Bitching aside it looks like a pretty well made product. I was wondering about washing the Climateline hose but it seems the heating element and sensor wire is on the outside. So washing it seems to be okay, at least the directions say to.

Otherwise everything is very straight forward and not difficult to figure out at all.

First thing I did is make a copy of all the files on the data card so if I ever mess that one up I can easily make a new one. Any SD card will work.
I had been concerned when Dreamdiver couldn't get data from his card after the first time he tried it and looking on Resmed's site I saw they had a custom USB thumb drive for it and I thought " why would they go to the expense of making a custom thumbdrive if any SD card reader is going to work " so I was afraid they had jimmied it so we had to have their special thumbdrive. But, fortunately that isn't the case. WHEW !!!
UPS can be hit or miss, I've had packages returned to sender as they could not find my address.
The signature requirement thing is down to cpap.com as they are the sender and are the ones to request signature as far as I'm aware.
Good point on copying the SD files though i did not think of that, I'm going to buy an SD backup card,do you know what size it is?

Please let us know how you get on with the machine and for me i would like to know what climate control/humidifier settings you favor

Good luck
UB

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Re: Using the S9 Autoset w/ Centrals... Suggestions appreciated

Post by DreamDiver » Mon Mar 08, 2010 10:59 pm

DSM, SWS, Some late thoughts - I'm a little fried for the end of the day, but here are some responses.

Interesting about the FOT stopping after 10 seconds for OA's. When your airway is closed off (as in when I did the intentional OA), the mask jumps a little. The mask does not jump with CA's. I suspect the larger air column, and 'spongier' patency that pulmonary alveoli probably produce, probably cause a sort of capacitor effect, dampening the mask jump effect. It might be more likely to fully wake someone after 10 seconds of OA FOT than CA FOT.

What interests me further is that I do not see any patency feedback on a heartbeat frequency, since you could actually hear it in the audio sample from the M-Series Pro.

Lastly, consider that full-blown pulmonary periodicity may be abated partly by the use of the machine itself. Are classic examples of periodic breathing usually shown with or without xPAP assistance? I suspect without. xPAP may dampen the effect.

As to the hypopnea thing - so it involves multiple breaths with consecutively-reduced amplitude within at least a 10-second period to count as a hypopnea. Have I got that right? I'm learning something I didn't understand before. Does this image sum correctly? What about the item with the question mark? (See image below.) Is the definition of hypopnea sort of 'fluid' -- depending on which machine's algorithm and which doctor you talk to?
Image

From the articles, let me see if I understand correctly: there are at least six methods by which the body tries to regulate O2/CO2. They generally work in conjunction. One or more breaches in the various systems can cause period breathing. Chronic low-dose exposure or various high-dose exposures to neurotoxins could cause a breach in one or more of the regulatory systems. Cardiopulmonary family history or genetics can also contribute to other breaches in one or more of these regulatory systems. Is this the implication?

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Re: Using the S9 Autoset w/ Centrals... Suggestions appreciated

Post by -SWS » Mon Mar 08, 2010 11:29 pm

DreamDiver wrote: What interests me further is that I do not see any patency feedback on a heartbeat frequency, since you could actually hear it in the audio sample from the M-Series Pro.
I don't think Resmed can signal-process the cardiac oscillation signal (COS)---since that differentiation method is patent protected. And if they can't signal-process COS, then they might as well filter it out of the graphical reports.
Lastly, consider that full-blown pulmonary periodicity may be abated partly by the use of the machine itself. Are classic examples of periodic breathing usually shown with or without xPAP assistance? I suspect without. xPAP may dampen the effect.
It can work out either way. In the case of CompSAS/CSDB, the machine actually exacerbates/reveals the periodic breathing tendency. If your post-break central apneas are the result of central periodicity, then a gradual ramp might prove better or worse than no ramp---depending on your own CO2 based homeostatic adjustment tendencies during rapid sleep onset. Alternately, staying awake just a little longer with the mask on after bathroom breaks might help as well.
As to the hypopnea thing - so it involves multiple breaths with consecutively-reduced amplitude within at least a 10-second period to count as a hypopnea. Have I got that right?
Yes. If each of your breaths is on the order of 5 seconds, then it will take more than one breath to meet that 10-second requirement.
Is the definition of hypopnea sort of 'fluid' -- depending on which machine's algorithm and which doctor you talk to?
Yes, regarding hypopnea definitions varying from machine to machine ( see Velbor's chart). Doctors typically have the sleep labs or their own scoring technicians flagging apneas and hypopneas. And my understanding is that now days most labs in the U.S. tend to score hypopneas according to AASM criteria. But that was not always the case: http://ajrccm.atsjournals.org/cgi/content/full/159/1/43

Hypopneas are really volume-based flow reductions. But low tidal volumes can be roughly visually assessed by amplitudes. And sinusoidal volumes can even be algorithmically assessed by peak amplitude and sinusoidal pulse-width alone. So for our purposes, I think we can more easily eyeball peak sinusoidal amplitudes (like you have in the graph above) when lining up suspects for hypopnea scoring on your machine.

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Re: Using the S9 Autoset w/ Centrals... Suggestions appreciated

Post by unadog » Tue Mar 09, 2010 12:10 am

DreamDiver wrote: Are classic examples of periodic breathing usually shown with or without xPAP assistance? I suspect without. xPAP may dampen the effect.
On my cell phone, 1 am, so this is a bit messy ....

If you are dealing with symptoms of Complex Sleep Apnea that started with xPAP use, the waveforms almost by definition are during xPAP use. Some form of complex apnea occurs in about 15% of new CPAP users. It is often transitional, resolving itself in most case, 95% or so, within the first 8 weeks. But I think the broader definitions are used across the pulmonary field, so aren't based on treatment observations.

There are some slightly different numbers, sample waveforms, and some good discussion and citations, starting at slide #10 here:

http://www.ucsfcme.com/2010/slides/MOT1 ... isease.pdf


You can run through the list of types/causes of Complex Sleep Apnea to see if you can identify other factors that may apply to you. The statistical rate of occurences and other some obvious causes - congestive heart failure, etc. - should help you make a good guess about your situation.

Because it is a moving target, the data mining you are doing now is essential to helping you figure out how much of an issue it is/will be for you. There is a bit of disagreement among doctors about definitions, and how aggressively to treat. They are about at the conceptual stage where they are arguing whether bleeding, leeches, or low doses of arsenic are the best treatment ..... (The title of the slide set/lecture is "Complex Sleep Apnea - Is It A Disease?", from August 2009. At least this guy says yes!)

Hope that is mostly on track, or at least useful. I know it is a bit tangential. Never sure with my brain ..... I could ponder that for a few hours.

Cheers!
Michael
Last edited by unadog on Tue Mar 09, 2010 6:49 am, edited 2 times in total.
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Re: Using the S9 Autoset w/ Centrals... Suggestions appreciated

Post by dsm » Tue Mar 09, 2010 3:48 am

DreamDiver,SWS,UnaDog

Very interesting info & great reading

Thanks

DSM

UnaDog - the link appears to be failing ?
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Re: Using the S9 Autoset w/ Centrals... Suggestions appreciated

Post by DreamDiver » Tue Mar 09, 2010 6:40 am

Here's a repost to the link. Thanks Michael!
http://www.ucsfcme.com/2010/slides/MOT1 ... isease.pdf

I am basically just at my limit of understanding what's really happening here. Part of that is due, in part, to the effects of the centrals. I'm concerned that in writing to understand that what I've written might be seen as fact, when it's really more about wrapping my own head around it.

I've been on the same machine for several years. For the first bit, everything seemed to be improving. For my first night ever on the M-Series Pro, my AHI was 24. That came down over the course of a few days to 6. It took a couple months to figure out I needed to drop the cflex. That brought my AHI down to just over 2. Since then, it had been a case of titration t bring it generally below 2.

For years though, my AHI has hovered around 2, but I still wake up with massive headaches that don't go away during the day and brain fog that seems to be worsening. So I'm not sure it's a case of resolving Complex Apnea. It seems to be getting worse. So I know I'm benefiting to some extent from CPAP therapy, but something is either missing, or I need a different type of xPAP therapy.

In three labs, they remarked that they were seeing centrals, but logged me as OSA. My airway doesn't close off. I'm pretty sure it never has.

It's entirely possible that I have Complex Apnea. Can you have Complex Apnea without the obstructive element?

SWS - filtering real data out of raw wave reports on what seems like a whim sounds not only professionally and scientifically malfeasant, but extremely difficult to attain, given the fluctuations in heart beat, the other rhythms you would have to screen out, and the fact that things like FOT show up at such high resolution. I'm not sure filtering just heartbeat from raw wave data is would be worth the effort in math-hours. Plus it's tampering with raw data. If anything, I would expect them to leave it as is to let others draw their own conclusions based on pure data rather than a patented process, just like seeing periodic breathing in the wave forms. Filtering seems improbable.

The problem with ramp is that recording is excluded from that period. If I can't record it, I can't use it. My pressure is so low, I sense that ramp is unnecessary anyway.

Thank you for the better explanation of hypopneas. Again, I'm still wrapping my head around it.

Here are some definitions I've learned since starting this S9 journey:

Eupnea - in the human respiratory system, eupnea (Greek eupnoia; from eu, well + pnoia, breath) is normal, good, unlaboured ventilation, sometimes known as quiet breathing or resting respiration. In eupnea, expiration employs only the elastic recoil of the lungs.

Bradypnea - Bradypnea (Greek from bradys, slow + pnoia, breath), British English spelling bradypnoea refers to an abnormally slow breathing rate. The rate at which bradypnea is diagnosed depends upon the age of the patient.

Dyspnea - Dyspnea or dyspnoea (pronounced disp-nee-ah, IPA /dɪsp'niə/), from Latin dyspnoea, from Greek dyspnoia from dyspnoos, shortness of breath), also called shortness of breath (SOB) or air hunger, is a debilitating symptom that is the experience of unpleasant or uncomfortable respiratory sensations. It is a common symptom of numerous medical disorders, particularly those involving the cardiovascular and respiratory systems; dyspnea on exertion is the most common presenting complaint for people with respiratory impairment.

Tachypnea - Tachypnea (or "tachypnoea") (Greek: "rapid breathing") is characterized by rapid breathing. It is not identical with hyperventilation - tachypnea may be necessary for a sufficient gas-exchange of the body, for example after exercise, in which case it is not hyperventilation. Tachypnea differs from hyperpnea in that tachypnea is rapid shallow breaths, while hyperpnea is rapid deep breaths. Tachypnea can also be a symptom of carbon monoxide poisoning in which oxygen delivery to the tissues and organs is blocked causing hypoxia and direct cellular injury.

Hypercapnia - Hypercapnia or hypercapnea (from the Greek hyper = "above" and kapnos = "smoke"), also known as hypercarbia, is a condition where there is too much carbon dioxide (CO2) in the blood. Carbon dioxide is a gaseous product of the body's metabolism and is normally expelled through the lungs. Hypercapnia normally triggers a reflex which increases breathing and access to oxygen, such as arousal and turning the head during sleep. A failure of this reflex can be fatal, as in sudden infant death syndrome. Hypercapnia is the opposite of hypocapnia.

Hypocapnia - Hypocapnia or hypocapnea also known as hypocarbia, sometimes incorrectly called acapnia, is a state of reduced carbon dioxide in the blood. Hypocapnia usually results from deep or rapid breathing, known as hyperventilation. Hypocapnia is the opposite of hypercapnia.

Psychopnea - Pretending to breathe when one isn't.

Pseudopnea - Pretending not to breath when one isn't.

Torocoprolipnea - the sense that one is breathing a huge load of BS. AKA called crapnea.

Okay, I made up the last three. Can you tell I took Latin in highschool?

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Re: Using the S9 Autoset w/ Centrals... Suggestions appreciated

Post by unadog » Tue Mar 09, 2010 7:31 am

DreamDiver wrote:Here's a repost to the link. Thanks Michael!
Thanks. I fixed it in my post above too. One last time:

 http://www.ucsfcme.com/2010/slides/MOT1 ... isease.pdf
So I'm not sure it's a case of resolving Complex Apnea. It seems to be getting worse. So I know I'm benefiting to some extent from CPAP therapy, but something is either missing, or I need a different type of xPAP therapy.

In three labs, they remarked that they were seeing centrals, but logged me as OSA. My airway doesn't close off. I'm pretty sure it never has. 

It's entirely possible that I have Complex Apnea. Can you have Complex Apnea without the obstructive element?
There is pure "Central Apnea" on initial testing with no OSA.  But that is statistically rare (0.4% vs. 15% for Complex.) It usually has different causation too.  

If you read the passge below, though, it eventually becomes a question of definition only. You may enjoy the whole article. It is the "pro" side of the pro/con debate. There is a good section on "loop gain", periodic breathing, and centrals after this quote:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2576323/

The appearance of treatment-emergent central apnea is well known and recently described. However the identification of central apnea appearing years after treatment of obstructive apnea is an older observation. Fletcher reported on a patient who four years earlier underwent curative tracheostomy for severe OSA and then had a 23-kg weight gain. He redeveloped hypersomnolence and when restudied, apneas of similar frequency, duration, and depth of desaturation reappeared but were now totally central in origin.

The mechanisms behind this phenomenon and CompSA are not well understood, but some comments can be offered. Presumably there must be dual causation that includes anatomic and physiologic vulnerability to OSA plus a central breathing control instability leading to chemo-reflex dysfunction. High loop gain is required.
 

Back to sleep. I have slept 2 hours + 3 hours so far... I'll try one last time .....  

Michael
Last edited by unadog on Tue Mar 09, 2010 9:28 am, edited 1 time in total.
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