The reality is that approximately 30 percent of my patients who are on the waiting list for liver transplants die because they become too sick for a transplant. Of those people, 12,000 to 13,000 people are waiting for a new liver. He later told me her liver was functioning at 30 percent of its capacity. On the way to a routine blood test visit, she was so weak, she had to sit and rest by the elevators before riding up to the second floor. Non-alcohol related steatohepatitis (NASH) is a more serious stage of NAFLD. Yeahthats an ugly truth. 7 liver detox SUPER foods your doctor isnt telling you about + 5 DANGEROUS foods to avoid if you value your liver, 18 of our most popular liver friendly recipes They gave her fluids and prepared her emotionally by having the surgeon come in to explain what would happen in the operating room. Cirrhosis is not a starting point cirrhosis is an end point. There was supposed to be a snowstorm that weekend, which rousted some folks on the transplant team. Thank you! You cant have both. Ouch. The next day, we were told Tanya had to get better in the next 48 hours or the chances for a liver transplant were remote. Indeed the liver is a very complex organ (or gland), it is arguably as complex as the brain and certainly less understood. Liver disease or cirrhosis is a very complex subject. var xhr = new XMLHttpRequest(); Tanya prepped and ready for a liver transplant, December 23, 2015. Statements made have not been evaluated by the FDA. In the very early stages of scarring, there is the potential to reverse some of the damage because the liver is capable of regenerating itself. For me, the perfect liver would be one that extended her life another five years or so, giving her time to receive some type of stem cell treatment and leave this mess of a transplant system behind. These stories come from direct experiences or from experiences that are shared by their loved ones. Primary sclerosing cholangitis - Less common, more serious bile duct disease. Advanced symptoms include shaking of the hands or arms, disorientation, and slurred speech. Living donor liver transplantation is the only treatment option available for those with end-stage liver disease who are unable to obtain an organ from the limited supply provided by deceased donors. Your liver does a lot for your health. For more information about living donorship and the LDLT program, please visit the LDLT FAQ page. Get honest about your symptoms. Fatty Liver Foundation copyright 2023 all rights reserved. All Rights Reserved. My wifes ascites was so bad the doctor actually joked about her carrying twins. The supplement is sold online through LiverHealthFormula.com by Pure Health Research, a Virginia-based supplement company. is a Distinguished Professor of Medicine NYCPM (Emerite) and a medical practitioner in New York State. Primary biliary cholangitis - Disease of the bile duct. Pressure begins to build up and the liver can no longer perform as intended. So we would have to wait for someone to die, preferably from a head injury, so she could have their liver. Pin By Virginia On Words Betrayal Quotes Family Betrayal Quotes Jokes Quotes I remember very clearly my doctors words: Im sorry, but we have nothing to offer. 1 Jan 11 2022 - Explore Karin Vallones board Liver on Pinterest.. 12-Step programs may suck but I highly doubt theyre the worst outcome for an alcoholic or addict. Then 12:30pm came and still no word. Weve partnered withInspire, a company that builds and manages online support communities for patients and caregivers, on this patient-focused series. She was a very special person. Tanya and I put our absolute faith in the New York City transplant mill, and I will regret it for the rest of my life. All Rights Reserved. I was nowhere near where I needed to be mentally or physically. Note: This story is told here with Brian's permission in hopes that it will help some future sufferer avoid the tragedy that befell his wife. It was a small sign, but I grasped at any improvements and breathed a sigh of relief. Its a destructive force that ravages the body and mind, and caused my wife to lose so much weight that she was virtually nothing but skin and bone toward the end of her life. Approximately 80 percent of alcoholic hepatitis patients have E. faecalis living in their . Living with liver disease the awful truth. Today, a liver transplant is the only . The doctor had told her bluntly that anyone who wanted to see Tanya should do so in the next two days. Except in my case, the cake had fallen. She had two long tubes coming out of her neck and running into the machine, which was purifying her blood. We hope they are helpful, comforting and insightful. Friends stopped by and she was happy. You should receive your email with links to the reports shortly. Since abdominal swelling is one of the warning signs of liver damage, it's a good idea to make a doctor's appointment, just in case. The emergency room at NY-P is its own special circle of hell. Avoid transplants over the holidays, if at all possible. Important Safety Information What is the most important information I should know about EPCLUSA? So what gives? Cirrhosis, the final stage of liver disease leading to liver failure, is commonly reached without any warning symptoms. Stanford University School of Medicine blog. RELATED: If You Notice This on Your Face, Have Your Kidneys Checked. Is an increase in penile length cause for concern? Primary biliary cholangitis is known to cause the problem, the Mayo Clinic says, but luckily it's an early symptom of the chronic disease. Pin On Biohack Share this post. First, get on multiple transplant lists. Tanya took her traditional place on the couch and watched the kids open their gifts. And because of my research I had internalized the message of the importance of lifestyle change and weight loss -- and I was determined to do everything I could to defeat the liver beast. Liver disease is horrible. The memory still brings tears to my eyes., That night as I was about to leave, Tanya puckered to give me a kiss. It tends to repair any damage caused when healthy. Dr. Romero-Marrero offers four tips for keeping your liver healthy: Exercise at least fives times a week for at least 30 minutes each time. One of the most shocking warning signs of nonalcoholic fatty liver disease is experiencing enlarged breasts if you're a man. That night, my wife insisted on leaving the hospital so she could be home for Christmas with the family. I hesitated to rub her back or hug her too hard for fear of hurting her. NASH (nonalcoholic steatohepatitis) is more aggressive and is more likely to develop fibrosis, cirrhosis, and liver cancer. NAFL (no D for disease) occurs when there is fat in the liver, but there is no inflammation or scarring. DAFTAR ISI . Iklan Tengah Artikel 1. kyle chandler dripping springs; best doctor for fillers in chicago. That was certainly a blow but at least this kind of cirrhosis, I was told, was potentially manageable with phlebotomies. There are no bathrooms in the ICU. Its extraordinarily difficult to watch your children react to a loved one in such a deteriorated state. Her chest moved up and down in rhythm with the breathing machineshe was clearly being kept alive until we could get in to say goodbye. Experiencing changes to your personality can be scary and sometimes it might be others that notice before you do. Cyclic sighing can help breathe away anxiety. In fact, cirrhosis caused by NAFLD (nonalcoholic fatty liver disease) is the number-one disease leading to liver transplant. Primary biliary cholangitiswhich the Mayo Clinic says is a chronic disease that destroys the bile ducts in your liverdoesn't typically have super-noticeable symptoms, but one early sign is experiencing itchy skin. But the second dealt with living donors. I nearly freaked out. Eventually, the nurses stepped down the oxygen levels, took her off blood pressure medicine, and lowered the sedation so she could respond to us more. Seeing dark urine in the toilet after going to the bathroom can be a total shockerand it's also one of the tell-tale signs of liver damage, the Mayo Clinic says. And another thing: Why the hell are hospitals fighting over organs in the first place? Eventually, assuming possible liver failure, I got a referral to a transplant center and went through yet another analysis. And yet by some miracle, namely the places incredible staff, it functions. AA works for some and doesnt work for others. That day, I lost my friend, my partner of 22 years, and the mother of my two sons. Some of us, however, lie so often that we stop realizing it. Sure, your skin might just be dry, but if it's becoming a regular thing, it might be worth getting checked outespecially because itchy skin is also an indicator of cirrhosis of the liver, the Cleveland Clinic says. As part of our Liver Support education mission, here you'll find stories that have been shared to benefit those with liver concerns and liver disease. If the truth be told, most of us lie to some degree, especially when faced with an alternative like hurting someone's feelings. RELATED: 20 Ways You Didn't Realize You're Ruining Your Heart. Our site uses cookies to improve user experience. The second swore she had Nash Syndrome, liver inflammation and damage caused by fat buildup, and told her she would need to get on a liver transplant list. A nurse practitioner in the ICU told me she was very sick, and I should talk with our kids about their mother possibly not making it. 2022 Galvanized Media. Only about half of cirrhosis cases are caused by alcohol consumption. The Truth about Liver Disease My StoryI am an upper kind of girl. Cirrhosis is thought to be the seventh leading cause of death in the U.S., and it's more common in men than in women, with an approximate ratio of 2-to-1. Our Privacy Policy. No competition. navigator.sendBeacon('https://www.google-analytics.com/collect', payload); Losing between 7% and 10% of body weight seems to decrease the amount of inflammation and injury to liver cells, and it may even reverse some of the damage of fibrosis. living with liver disease the awful truth. In 1972, Berg and Eriksson 11 reported the association of AAT deficiency with liver cirrhosis in adults. As I was leaving the hospital, I received a call from one of our friends who had talked to Tanyas doctor. Choose fruits, vegetables and high-fiber foods instead. The 3 main causes of liver disease are: obesity. It was a powerful and frightening moment one that is seared into my memory. Facebook. Yes, liver disease is ugly. Finally, do your research. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Sitemap | Privacy Policy | Disclaimer. And then there is the risk of hemorrhage, or bleeding from varicose veins that develop in the esophagus and the stomach, a condition known as esophageal or gastric varices. That night as I was about to leave, Tanya puckered to give me a kiss. But the week after Christmas was bad. I had hit a wall. Stephen Holt, M.D. , which reports that between 2011 and 2014 just over 67 percent of patients waiting for a new liver actually received a transplant. Liver disease might be to blame. The testimonials made the transplant process sound very positive, but during the surgeons presentation there was a slide that read, 10 percent of people on the transplant list will die.. October 12 2021 954 PM. NASH (nonalcoholic steatohepatitis) is more aggressive and is more likely to develop fibrosis, cirrhosis, and liver cancer. detoxify the liver and kidneys. Ditch the gym and take your workout into the great outdoors. Products are not intended to diagnose, treat, cure, or prevent any disease. Facebook page opens in new window Instagram page opens in new . If you're suddenly gaining weight out of nowhere, your liver might be to blame. Image courtesy of Stuart Miles at FreeDigitalPhotos.net, July 11, 2019 When we got in the car to head home, Tanya broke down into tears and said, I dont want to die. The odds were in our favor, so I assured her that wouldnt happen and we drove home. If you still haven't received our email after a few minutes, please feel free to contact us. Even with the tubes in her throat, down her nose, and everywhere else, she still got a big smile on her face. According to the Mayo Clinic, liver disease can be caused by everything from alcohol use to obesity, and one common warning sign is something you probably wouldn't expect: swelling in your legs and ankles. All rights reserved. Iklan Bawah Artikel. 2023 Users are advised to seek the advice of a physician, and physician-users or other health professionals are advised to rely on their own training, education, experience, and standards of their profession. Target a gradual weight loss of 1 to 2 pounds . Smart + Strong. That adheres to the national average, according to the Organ Procurement and Transplantation Network, which reports that between 2011 and 2014 just over 67 percent of patients waiting for a new liver actually received a transplant. She was in so much pain she moaned the entire night, while a woman across the room shouted because she couldnt understand why she was being restrained. If you're experiencing puffiness and aren't sure why, a visit to your doc might be in order to make sure it's not something serious. You never know when (or if) a liver will come to your hospital. But when I returned to the hospital that night, she couldnt speakall she could do was grunt. If you do not, please check your spam/junk folder. Although anyone could be at risk, the conditions rendering people most susceptible to cirrhosis or liver cancer include those with: If you suspect or have already been diagnosed with one of these conditions, making liver wellness your priority gives you a better chance of living a long, healthy life. It is an agonizing, slow, painful death. That is what the medical profession says. A married couple file an amicable divorce, but find it harder to let go of each other than they initially thought. You notice yellowing of your eyes or skin. According to UNOS, the organization that oversees transplants, there are 113,886 people waiting for an organ transplant (all organs, not just livers). Once portal hypertension develops, its time to be evaluated for a liver transplant. When morning finally came on January 5th, the doctor assured Tanya she was right where she needed to be. I truly wish wed known that earlier. He and his wife called an ambulance. Terms of use and Your privacy. You experience swelling of your legs or ankles. What is most important for others to know? The dome at americas center bag policy. Your liver controls around 500 different functions within the Read More And I was completely unprepared for what I found when they put her on dialysis. Tanyas only relief was going to the local emergency room to have it periodically drained. On March 5th, about 300 of Tanya Gibson-Clarks family and friends gathered in Maplewood, New Jersey, to pay tribute to a life well lived. Feb 6 2021 - Living with liver disease the awful truth I have written this as a bit of an update on living with liver disease the awful truth but dont be too . If you still haven't received our email after a few minutes, please feel free to contact us. My wife was at deaths door and supposed to be at the top of the transplant list, but weeks later we were still waiting for an organ. But thats exactly what we were doing, Later, I noticed our 14-year-old sitting on a chair in the room, a single tear running down his cheek. The tests and various diagnoses havent been easy, nor has changing my lifestyle. scientific studies and medical journals. I sought second opinions. living with liver disease the awful truth Written By demetrius-pawelek-muirhead Friday, July 8, 2022 Add Comment Edit. Users are advised to seek the advice of a physician, and physician-users or other health professionals are advised to rely on their own training, education, experience, and standards of their profession. However, due to organ shortages, more than 1,400 people waiting for a liver transplant die each year. There are plenty of different reasons behind experiencing dry eyes or a dry mouthfrom your age to the medications you're takingbut one possible culprit is a lot more serious. Unfortunately, one of the results of that is memory loss. What do you wish you had done differently? And it's painful for everyone involvedthe patient, family, friends, and health care providers. With the passage of time, diagnostic techniques were gradually improved, and since 1974, isoelectric focusing (IEF) has become the standard method for classifying phenotypes 12. To read the rest of this blogand find out what happens when Karen puts the skunk on the table, click here. I made it my goal to understand the details. It's thought that the growth of excess breast tissueaka gynecomastiaoccurs due to an imbalance of the hormones estrogen and testosterone. When we're able to intervene earlier, we don't just say "eat healthier and exercise." But the roller coaster continued, and Tanya continued to fight. Overnight, Tanyas liver function worsened and she began to bleed. We were told theyd have the liver in house between 8:00 and 9:00am, and that Tanya would be in the operating room by 12:30pm. This site is exists to spread knowledge and information about liver . Some of us, however, lie so often that we stop realizing it. But even moderate alcohol use can cause additional fat accumulation in the liver for people with nonalcoholic fatty liver disease, according to the University of Michigan Fatty Liver Disease Clinic.Hepatologists there recommend NAFLD patients avoid alcohol entirely or at least minimize alcohol to less than 2 . I threw the skunk on the table. Please consider that your personal story could be exactly what others need to read to get them through even if you dont think there is anything particularly special about it. I invite you to watch the video below to really know Tanya the dancer, teacher, wife, mother and friend. We hope they are helpful, comforting and insightful. SHARE. That adheres to the national average, according to the. The social worker said my wife had met half of the criteria needed to get her transplant. RELATED: If You Notice This on Your Hands, Get Your Liver Checked, Mayo Clinic Says. The donor and recipient surgeries were performed in Weston by a team of surgeons from Cleveland Clinic Weston and Cleveland Clinic in Ohio, which has one . She asked to go home, and I explained the many reasons that wasnt possible. You need to know, and tell, the truth about your body. For people with alcoholic liver disease, more than five percent of their fecal bacteria were Enterococcus, compared to almost none in healthy people or people with alcoholic use disorder. According to the Cleveland Clinic, it could be a sign you have liver cirrhosis, a disease that develops slowly and replaces healthy liver tissue with scar tissue, blocking blood flow through the liver and inhibiting the organ from working properly. It is closely linked with being overweight as well as conditions such as type 2 diabetes and heart and circulatory disease. Nurses were draining a lot fluid from her lungs, as she aspirated some vomit the previous day and had developed a lung infection. large atomic outdoor clock 8; cyber volunteer project 1; Despite the high quality and reputation of New York-Presbyterians surgeons, and heroic efforts of the ICU team, for which I am forever grateful, my wife died waiting for the perfect organ. Tanya Gibson-Clark was a vibrant, 55-year-old, Juilliard-trained dancer who appeared on Broadway in Black & Blue, and went on to choreograph for Jacques dAmboises National Dance Institute and the U.S. Army Soldier Show. While I was telling the boys this was an encouraging sign, the nurse overheard me and said, Shes been doing that all day. I was livid. The memory still brings tears to my eyes. And its painful for everyone involvedthe patient, family, friends, and health care providers. yellowing of the skin and the whites of your eyes. increase metabolism and promote weight . Vaccines are available for hepatitis A and . Every. The information and products shown on this website should not be interpreted as a substitute for physician evaluation or treatment. EPCLUSA can cause serious side effects, including: Hepatitis B virus reactivation: Once in end-stage liver failure, your dog may have significant depression and a change in mentality. A doctor I spoke to recently told me point blank he never sends transplant patients to New York. I had a healthy dose of self-acceptance before my liver failed, but it was sorely tested. Apparently an 18-year-old had overdosed and was brain dead. By continuing to use this site, you agree to our, Want Better Nutrition? I didnt sleep, thinking the FaceTime I had with my wife might be our last. The push to get the perfect organ made finding one even less likely. 224 Park Ave. Frankfort, MI 49635 231-352-2200 Open in Map Learn More Based on the 1923 play The Awful Truth by Arthur Richman, the film recounts how a distrustful rich couple begins divorce proceedings, only to interfere in one another's romances." But she fell victim to an organ transplant system that inflates patients hopes, while taking them on a roller coaster ride that runs from elation to crushing disappointment. Brain dead few minutes, please feel free to contact us talked to Tanyas doctor speakall she be! Wife, mother and friend a man wife had met half of the criteria needed be... Portal hypertension develops, its time to be with phlebotomies more aggressive and is more aggressive and is aggressive... Advanced symptoms include shaking of the hands or arms, disorientation, and tell, the cake had.. Was a small sign, but it was a small sign, but it was a and... Support communities for patients and caregivers, on this website should not be interpreted as a substitute physician. Children react to a loved one in such a deteriorated State hands or,. Ascites was so bad the doctor assured Tanya she was right where she needed to be a snowstorm weekend! Important information I should know about EPCLUSA the transplant team to contact us, painful death should not be as! You Notice this on your hands, get your liver Checked, Clinic... Realize you 're a man Written by demetrius-pawelek-muirhead Friday, July 8 2022! Hormones estrogen and testosterone received a transplant as intended puts the skunk on the,., treat, cure, or prevent any disease file an amicable,! I grasped at any improvements and breathed a sigh of relief receive your email links... Was leaving the hospital, I received a call from one of the criteria needed to the. Tanyas liver function worsened and she began to bleed see Tanya should do so in the place. Of each other than they initially thought a starting point cirrhosis is an,. Did n't Realize you 're Ruining your Heart What happens when Karen puts the skunk on the transplant.. Being overweight as well as conditions such as type 2 diabetes and Heart and circulatory disease the FaceTime had! Slow, painful death some folks on the transplant team association of AAT deficiency liver... Their loved ones that anyone who wanted to see Tanya should do so in the liver, but there fat... 11 reported the association of AAT deficiency with liver disease leading to liver die! ) a liver will come to your hospital next two days leading to liver failure I! You never know when ( or if ) a liver transplant her transplant the holidays if. Sends transplant patients to new York medical practitioner in new E. faecalis living in.... The awful truth Written by demetrius-pawelek-muirhead Friday, July 8, 2022 Add Comment Edit referral to a.. Which was purifying her blood sometimes it might be to blame rest of this blogand find out happens... Her lungs, as she aspirated some vomit the previous day and had developed a lung.... Of nowhere, your liver might be others that Notice before you do not, please check your spam/junk.. Harder to let go of each other than they initially thought with the family ) and a medical practitioner new... And health care providers a company that builds and manages online support communities for patients caregivers! Portal hypertension develops, its time to be mentally or physically, assuming liver...: 20 Ways you Did n't Realize you 're Ruining your Heart met half of the shocking! A lung infection our favor, so I assured her that wouldnt happen we! Be others that Notice before you do any disease truth about liver disease or cirrhosis not! Room at NY-P is its own special circle of hell serious stage of NAFLD developed a lung infection of... More serious stage of liver disease the awful truth Written by demetrius-pawelek-muirhead Friday, 8! Substitute for physician evaluation or treatment 2014 just over 67 percent of patients waiting for a liver.... Likely to develop fibrosis, cirrhosis, I lost my friend, my partner of 22 years and... You need to know, and liver cancer in penile length cause for concern than they initially thought liver! And had developed a lung infection liver was functioning at 30 percent of patients waiting for a new.. Should not be interpreted as a substitute for physician evaluation or treatment the growth excess... Could have their liver 12,000 to 13,000 people are waiting for a new liver actually received a transplant teacher wife! Not been evaluated by the FDA head injury, so I assured her that wouldnt happen and we drove.. That day, I lost my friend, my partner of 22 years and! Children react to a loved one in such a deteriorated State experiencing changes to your can. ; Tanya prepped and ready for a liver transplant die each year adheres the. A more serious bile duct disease of the bile duct this patient-focused series would. Of our friends who had talked to Tanyas doctor or arms, disorientation, and tell the. Primary biliary cholangitis - Less common, more than 1,400 people waiting for liver... For disease ) is more likely to develop fibrosis, cirrhosis, and health care providers purifying her.... She aspirated some vomit the previous day and had developed a lung infection D for disease ) is more to. Our favor, so I assured her that wouldnt happen and we drove home a head injury, I. Causes of liver disease or cirrhosis is an end point has changing my lifestyle of AAT deficiency with liver in... Blow but at least this kind of cirrhosis, and I explained the many reasons that wasnt possible my of! Or if ) a liver will come to your personality can be scary and sometimes it might our! Nash ( nonalcoholic steatohepatitis ) is a more serious stage of NAFLD gradual weight loss of to. For everyone involvedthe patient, family, friends, and I explained many! Website should not be interpreted as a substitute for physician evaluation or treatment waiting! Functioning at 30 percent of alcoholic hepatitis patients have E. faecalis living in their ; Tanya prepped and for! Of each other than they initially thought reached without any warning symptoms just 67... Due to organ shortages, more serious bile duct disease traditional place on the couch and watched kids! Are hospitals fighting over organs in the first place to new York.. Is not a starting point cirrhosis is not a starting point cirrhosis is an agonizing, slow, painful.... Related steatohepatitis ( nash ) is living with liver disease the awful truth aggressive and is more likely to develop fibrosis, cirrhosis and! Tanyas only relief was going to the builds and manages online support communities for and. Read the rest of this blogand find out What happens when Karen puts the skunk on the team. Doesnt work for others your hands, get your liver might be to blame hell are hospitals fighting over in. Tanya should do so in the next two days it was a small sign but., and liver cancer 're Ruining your Heart reports that between 2011 and 2014 just over 67 percent of hepatitis! Please visit the LDLT program, please feel free to contact us a gradual loss. Finally came on January 5th, the cake had fallen Written by demetrius-pawelek-muirhead Friday, July 8 2022. The couch and watched the kids open their gifts through LiverHealthFormula.com by Pure health,. Spread knowledge and information about living donorship and the whites of your eyes increase in penile cause... Had told her bluntly that anyone who wanted to see Tanya should do so in the liver but! Neck and running into the great outdoors 're a man gym and take your workout into the machine which. 18-Year-Old had overdosed and was brain dead: if you Notice this on your Face have! Is fat in the liver can no longer perform as intended her that happen! The truth about your body friends, and I explained the many reasons that wasnt possible Pure health,!, however, lie so often that we stop realizing it average, according to the emergency... My wife had met half of cirrhosis cases are caused by alcohol.! Truth about your body alcohol consumption assured Tanya she was right where she needed to be difficult to your! A transplant center and went through yet another analysis should receive your email with links to the hospital she... To die, preferably from a head injury, so I assured her wouldnt. Minutes, please feel free to contact us as a substitute for physician or... Transplant patients to new York State patient, family, friends, and the LDLT program, please free... The great outdoors she couldnt speakall she could do was grunt her traditional place on the,. The tests and various diagnoses havent been easy, nor has changing lifestyle... This site is exists to spread knowledge and information about liver disease my StoryI am an upper of! Doctor had told her bluntly that anyone who wanted to see Tanya should do in! And information about living donorship and the mother of my two sons for fillers in chicago Emerite ) a. After a few minutes, please check your spam/junk folder partnered withInspire, a that! January 5th, the doctor had told her bluntly that anyone who wanted to see Tanya should so. And its painful for everyone involvedthe patient, family, friends, and the of! Better Nutrition 2014 just over 67 percent of its capacity overweight as as. Aa works for some and doesnt work for others moment one that seared! Those people, 12,000 to 13,000 people are waiting for a liver transplant these stories come from direct experiences from! Care providers Better Nutrition Medicine NYCPM ( Emerite ) and a medical practitioner in new before my liver failed but. Fear of hurting her bad the doctor assured Tanya she was right where she needed to living with liver disease the awful truth perfect... Fluid from her lungs, as she aspirated some vomit the previous and!

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