tendonitis after covid vaccine

Even though the two major COVID-19 vaccines available today are around 94% effective, you should continue to follow all community rules and precautions concerning COVID-19 after vaccination. Opens in a new tab or window, Visit us on YouTube. A spokesperson for HRSA confirmed to MedPage Today via email that despite full FDA approval, Pfizer's COVID-19 vaccine (Comirnaty) still remains covered under the CICP and does not yet move to the VICP. Some of the side effects that occur after vaccination, such as fever, muscle aches and pain, and fatigue, may resemble symptoms related to an underlying condition. Now this toilet injury number may not seem directly comparable to the vaccine anaphylaxis numbers. What is the latest research on the form of cancer Jimmy Carter has? Questions and Answers for Patients Regarding Elective Surgery and COVID-19. I called the testing center. Epub 2021 Oct 1. 5. official website and that any information you provide is encrypted Keeling and Kennedy both emphasized that while SIRVA requires further study, it does appear to be rare, and that the benefits of vaccination against COVID-19 far outweigh any potential risks. It's difficult to take x-rays and do long procedures as an oral surgeon: "I have pretty good pain even with just normal function now," he said. Musculoskeletal corticosteroid injections are common procedures which are most often performed in an elective, outpatient setting. 2 cm deep to the quadriceps tendon and involved the medial and lateral gutter (, Arthrocentesis of the right knee showed 24 mL of inflammatory-appearing effusion (, His rheumatoid arthritis was well controlled before the vaccination, and there were no other inciting events, so we believe that this flare might have been triggered by his immune response to a component of the BNT162b2 vaccine. Vaccine. An infection with the SARS-CoV-2 virus may cause new or worse symptoms. In a 2021 study, researchers tried to gauge how common this is. Just a few seconds after the needle penetrated my arm, I felt a mild soreness, kind of like a flu shot. Here, we report a rare case of an 83-year-old woman who was diagnosed with calcification in her left shoulder 1 year ago and developed calcific tendinitis after receiving an mRNA vaccine for COVID-19 (Pfizer-BioNTech). How Viagra became a new 'tool' for young men, Ankylosing Spondylitis Pain: Fact or Fiction. SBI Recommendations for the Management of Axillary Adenopathy in Patients with Recent COVID-19 Vaccination . 2022 Jul 11;28:e937430. But for some people, symptoms are more severe, long lasting and even bizarre, including rheumatoid arthritis flares,. Med Sci Monit. Even if the vaccine is inadvertently injected into either of these spaces, studies have shown that it will have no harmful side effects. If you have any questions or need more information, please contact your orthopaedic surgeon. 401,887 people reported to have side effects after getting Pfizer BioNTech Covid Vaccine. Research suggests that overactive bladder and COVID-19 have links. (Photo: Getty) getty. 18 January 2021. No studies have found a direct link between the vaccine and arthritis. We Can Print Them, Human-Approved Medication Brings Back 'Lost' Memories in Mice, See No Evil: People Find Good in Villains, Study Unexpectedly Finds Only Seven Health Symptoms Directly Related to 'Long COVID', Long COVID Patients and Those With Other Illnesses Experience Similar, Negative Lingering Effects During the Pandemic, Children Infected With a Mild Case of COVID-19 Can Still Develop Long COVID Symptoms, Research Reveals Mechanisms Behind 'COVID Toes', CCPA/CPRA: Do Not Sell or Share My Information. Electrodes Grown in the Brain -- Paving the Way for Future Therapies for Neurological Disorders, Wireless, Soft E-Skin for Interactive Touch Communication in the Virtual World, Want Healthy Valentine Chocolates? Keeling and Brent Wiesel, MD, also an orthopedic surgeon at MedStar Georgetown University Hospital in Washington, D.C., recently published an overview of SIRVA in the Journal of the American Association of Orthopaedic Surgeons, stating that it's a "rare yet increasingly recognized complication of immunization.". Symptoms can vary depending on where the aberrant shot landed, resulting in various manifestations such as bursitis, tendonitis, or adhesive capsulitis (also known as "frozen shoulder"). Scott Noren, DDS, an oral surgeon in Ithaca, New York, said he also developed significant pain in his left shoulder after his second COVID shot in early February: "It went in pretty deep and pretty high," he told MedPage Today. References: HRSA Countermeasures Injury Compensation Program: Link or toll-free number 1-855-266-2427 RSA Vaccine Compensation Program Frequently Asked Questions: LInk Generally, it's characterized as a "constellation of shoulder pain and reduced range of motion that occurs within 48 hours of vaccination and does not resolve within 1 week," according to a. Tinnitus in Tapazole, how severe and when it was recovered? Recap. The symptoms of reactive arthritis can range from mild to severe. The COVID-19 vaccine may trigger an RA flare in people who already have the condition, but experts still strongly urge people with the condition to get vaccinated. Share on Facebook. thought to occur as a result of unintended injection of vaccine antigen or trauma from the needle into and around the underlying The U.S. Centers for Disease Control and Prevention (CDC) lists common COVID-19 vaccine side effects as pain, swelling or redness at the injection site; fatigue; headaches; muscle pain; chills;. If you have any questions about the timing of your surgery, your orthopaedic surgeon will be able to guide you. I'm still discovering new areas of damage -- Richard Quest. Common reactions include: Swelling or redness at the site of the injection Systemic reactions, such as fever, chills, nausea, vomiting, muscle aches, or fatigue "The . Tendonitis is found among people who get Pfizer BioNTech Covid Vaccine, especially for people who are female, 60+ old, and in the first week of getting the vaccine. The second possibility sounds like it could be carpal tunnel syndrome. It's also different from typical post-injection soreness, as the pain is more severe and it can impact mobility and function. The nasopharyngeal swab was negative for SARS-CoV-2 30 days after the first symptoms. Jackson can still do her job as a veterinarian, but it can be painful lifting animals during surgery, for instance. Treatment for joint pain is available. The pain largely resolved but returned, albeit to a lesser extent, after 6 weeks, and a follow-up MRI confirmed persistent bursa inflammation. Phase IV trials are used to detect adverse drug outcomes and monitor drug effectiveness in the real world. (2021, February 18). Systemic reactions in persons aged 6-23 months, Pfizer BioNTech BNT162b2 COVID-19 vaccine and placebo a Any fever= 38.0C b Mild: decreased interest in eating; moderate: decreased oral intake; severe: refusal to feed; Grade 4: emergency room visit or hospitalization Read on to learn about the possible association between a SARS-CoV-2 infection and joint swelling. While healthcare providers anticipate a sharp increase in reported cases in the coming year given the large volume of COVID vaccinations, Wiesel and Keeling warned that data on the condition are still limited -- they're "virtually absent from the orthopedic literature" -- and that the "current understanding of the diagnostic workup of SIRVA is limited to the medicolegal realm.". In such cases, the goal of therapy is to relieve symptoms and prevent long-term complications. The other injuries to receive compensation were anaphylaxis, shoulder pain, bursitis and one death. Dr. Accessibility Radiol Case Rep. 2021 Dec;16(12):3631-3634. doi: 10.1016/j.radcr.2021.08.019. The CDC recommends that you have the COVID-19 vaccine even if you have had an allergic reaction to food, oral medications, pets, or environmental toxins, such as dust or latex, in the past. Some reports may have incomplete information. Two of the vaccines, BNT162b2 (BioNTech-Pfizer) and mRNA-1273 (Moderna), are novel mRNA-based vaccines delivered via lipid nanoparticles. However, the report does not confirm that this happened. An official website of the United States government. Before The tinnitus remains after six weeks with no end in sight. Children and teens ages 6 months-17 years Adults 18 years and older After a second shot or booster Link; Grimm L, et al. Opens in a new tab or window, Visit us on Facebook. How can imaging lead to better treatment? If you are scheduled for elective orthopaedic surgerysuch as an arthroscopy or a joint replacementand you have received one or two doses of the vaccine, you may wonder if it is safe to proceed with your procedure. Tinnitus can develop after any vaccine and tends to happen more often with other vaccines. "The pain and the fatigue from the COVID-19 vaccine can overlap with axial spondyloarthritis symptoms, but the vaccine symptoms tend to be more widespread and usually not localized to singular joints," says rheumatologist John Miller, MD, Instructor of Medicine in the Division of Rheumatology at Johns Hopkins Medicine. Since the COVID-19 vaccine does not contain live or attenuated virus material, it cannot give you the disease. Sometimes surgery is needed to treat an underlying pathology such as an exacerbated rotator cuff injury. Other possible symptoms include: Although long COVID is more common in people who have had a severe case of COVID-19, it can happen even in those with a very mild case. COVID-19; Calcific tendinitis; mRNA; shoulder injury related to vaccine administration; vaccine. 2004-2023 Healthline Media UK Ltd, Brighton, UK, a Red Ventures Company. Muscle soreness and achy joints are common symptoms among COVID-19 patients. 20052022 MedPage Today, LLC, a Ziff Davis company. Can the Cornonavirus Affect My Bones and Joints? This information is provided as an educational service and is not intended to serve as medical advice. To update your cookie settings, please visit the, https://doi.org/10.1016/S2665-9913(21)00108-9, Flare of rheumatoid arthritis after COVID-19 vaccination, https://www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines/mrna.html, https://www.rheumatology.org/Portals/0/Files/COVID-19-Vaccine-Clinical-Guidance-Rheumatic-Diseases-Summary.pdf, Download .pdf (.2 2022 Aug 12;40(34):4964-4971. doi: 10.1016/j.vaccine.2022.06.002. Vaccination infrequently causes severe, persistent . Stroke in Tamsulosin, how severe and when it was recovered? Opens in a new tab or window, Visit us on TikTok. If the infection is no longer active, this type of treatment does not help. COVID-19 vaccine clinical guidance summary for patients with rheumatic and musculoskeletal diseases. We treated the patient with celecoxib and acetaminophen, and she recovered after about 2 months. Achilles tendinitis is an overuse injury of the band of tissue that connects your calf muscles at the back of the lower leg to your heel bone. Follow. Health regulators state that all vaccines have side effects and the most common can include pain in t Last medically reviewed on December 11, 2022. There is no evidence that vaccination will interfere with your surgery or recovery. ScienceDaily. Shoulder injury related to vaccine administration, or SIRVA, has been documented long before COVID-19 vaccination, and is most frequently reported after influenza vaccination. As the long-awaited COVID-19 vaccine rollout begins across the country and everyone is eager to get back to normal life, it can be confusing to understand what you can and cannot do once you and those around you are vaccinated. Unauthorized use of these marks is strictly prohibited. Three COVID-19 vaccines have been approved for emergency use in the USA so far. Northwestern University. Of the initial COVID-19 claims, the . . Generally, it's characterized as a "constellation of shoulder pain and reduced range of motion that occurs within 48 hours of vaccination and does not resolve within 1 week," according to a recent paper Keeling co-authored. The phase IV clinical study analyzes which people get Pfizer BioNTech Covid Vaccine and have Tendonitis. DISCLAIMER: All material available on eHealthMe.com is for informational purposes only, and is not a substitute for medical advice, diagnosis, or treatment provided by a qualified healthcare provider. MB), Help with Medical News Today has strict sourcing guidelines and draws only from peer-reviewed studies, academic research institutions, and medical journals and associations. People may mistake these symptoms for arthritis. The initial symptoms of fever, cough, nausea, diarrhoea, and dysgeusia improved progressively until they resolved completely within 30 days. If you are having a corticosteroid injection for an orthopaedic condition, such as arthritis or carpal tunnel syndrome, your doctor may advise you to wait for a few days after the injection before receiving the COVID-19 vaccine. "I have previous tests to prove . Is the ketogenic diet right for autoimmune conditions? According to a 2021 study, post-COVID-19 arthritis may occur as a result of inflammation, which is part of the bodys natural immune response. Symptoms include sudden onset joint pain and swelling, often in multiple joints. Rashes in Tarceva, how severe and when it was recovered? That cancer patients delay all imaging for 4 to 6 weeks after the COVID vaccine. (2022). Usually appearing up to 48 hours after vaccination, SIRVA is the result of a medical worker administering the vaccine "too high up" on the upper arm. Wiesel and Keeling's paper notes that since the VICP was created in the late 1980s for childhood vaccine injury, the demographic has shifted, with more than 50% of claims now involving adults. The patient provided informed consent to publish this case. In some cases, it may lead to arthritis flare-ups in people who already have RA. There is still a very small chance that you can get COVID-19. Is there a link between overactive bladder and COVID-19? If someone believes they may have long COVID, they should make an appointment with a doctor, who can create a medical management plan for them. Nonetheless, it would not have applied to COVID vaccines, which fall under a different compensation program. However, there wasn't enough research to determine if . All rights reserved. from the American Academy of Orthopaedic Surgeons, Swelling or redness at the site of the injection, Systemic reactions, such as fever, chills, nausea, vomiting, muscle aches, or fatigue. COVID-19 vaccine trials provide valuable insight into the safety and efficacy of vaccines, with individually-randomized, placebo-controlled trials being the gold standard in trial design. Note as well that despite the recent full FDA approval for the Pfizer COVID-19 vaccine, any injuries attributed to it at the present time still remain covered under the CICP. If joint pain occurs as a result of long COVID, the symptoms could be unpredictable. Sex and gender exist on spectrums. According to the Food and Drug Administration (FDA), monoclonal antibodies are proteins made in a laboratory that mimic your body's immune response. Both programs are administered by the Health Resources and Services Administration (HRSA). Arthritis can develop or flare up for many reasons. One of these cases involves the ulnar nerve ( 4 ), which is rarely reported in PTS ( 1, 14 ). This may help reduce symptoms and increase quality of life. The typical symptoms of COVID-19 range from those resembling the flu or a bad cold to ones that are much more severe. The paper will be published Feb. 17 in the journal Skeletal Radiology. The reactions can also be. We study millions of patients and 5,000 more each day. Other Northwestern authors on the paper were Santhoshini Leela Ramani (Northwestern University medical student), Dr. Jonathan Samet (radiology), Dr. Colin Franz (PMR and neurology), Dr. Christine Hsieh (rheumatology), Dr Cuong Nguyen (dermatology) and Dr. Craig Horbinski (pathology). All rights reserved. KAT authored the paper with edits made by FKT. Like any vaccine, a COVID-19 vaccine may cause pain, swelling, and fever after being administered. However, such a table does not exist yet for the CICP, the spokesperson said. SIRVA can be avoided with correct vaccination technique as described. Have any problems using the site? Tendonitis Send story tips to k.fiore@medpagetoday.com. This article will use the terms male, female, or both to refer to sex assigned at birth. Claimants must prove the vaccine caused the injury, unless it's covered under an injury table for CICP. "I just can't move my arm in certain motions," she said. All data and statistics are based on publicly available data at the time of publication. Skin reactions to the COVID vaccine aren't just limited to where you get your jab. Can diet help improve depression symptoms? Instead of going into the muscle, the vaccine goes into the shoulder bursa, causing a strong immune reaction. If you are allergic to polyethylene glycolone of the ingredients used in the COVID-19 vaccinethe CDC advises against being vaccinated. "In some patients, the nerves are injured (bright, enlarged) and in others, the problem is impaired blood flow (clots).". There is one caveat, however. Note: Content may be edited for style and length. it causes swelling, ulcerations, and loss of function of the large intestine), Urinary incontinence (inability to control the flow of urine and involuntary urination), Urinary retention (the inability to completely or partially empty the bladder), Urticaria (rash of round, red welts on the skin that itch intensely), Vaccination site erythema (redness around vaccination site), Vaccination site pruritus (severe itching of the skin at vaccination site), Vasculitis (inflammation of a blood vessel or blood vessels), Ventricular extrasystoles (premature cardiac contraction), Ventricular tachycardia (rapid heartbeat that originates in one of the lower chambers (the ventricles) of the heart), Vitreous floaters (spots before the eyes), Weight bearing difficulty (difficulty due to weight of thigh fat deposition), Wheezing (a high-pitched whistling sound made while you breath). The use of the eHealthMe site and its content is at your own risk. Therefore, to be safe, it's best to wait at least 14 days after you were either diagnosed with Covid-19 or started having Covid-19 symptoms before getting a Covid-19 vaccine. The HRSA spokesperson said the CICP covers "eligible serious injuries" -- generally, those that require hospitalization or that lead to significant disability. It is not intended to provide medical or other professional advice. "Some doctors request imaging for patients with 'COVID toes,' for example, but there wasn't any literature on imaging of foot and soft tissue complications of COVID," Deshmukh said. COVID-19 is a life threatening condition, and the vaccine is highly protective against the virus SARS-CoV-2, which causes . They discovered a strong association between post-COVID-19 arthritis and inflammation but not between post-COVID-19 arthritis and autoimmunity. One of these conditions is rheumatoid arthritis (RA). As a total percentage of claims, SIRVA rose from 1.8% to 40.7% during that time, they reported. Symptoms from improperly administered vaccinations - known as SIRVA, for "shoulder injury related to vaccine administration'' - include chronic pain, limited This may lead to joint pain, eye inflammation, and symptoms that affect various parts of the body. However, it is not known if the vaccine will cause a positive antibody test in patients who have been vaccinated but not had the virus. Instead, a piece of laboratory-manufactured genetic material called messenger RNA (mRNA) is injected. AAOS gives its full support for the widespread adoption of the vaccine. Financial support for ScienceDaily comes from advertisements and referral programs, where indicated. Cardiovascular health: Insomnia linked to greater risk of heart attack. 2021 Nov;50(11):2293-2297. doi: 10.1007/s00256-021-03803-x. The report focuses on a 53-year-old man with a family history of RA. . The vaccines that have been developed to protect against COVID-19 differ from traditional vaccines in that they do not inject a live or deactivated virus into the body. The AAOS Patient Safety Committee recommends avoiding musculoskeletal corticosteroid injections for two weeks before and one week after COVID vaccine administration. Would you like email updates of new search results? Copyright 1995-2021 by the American Academy of Orthopaedic Surgeons. Most people witness these side effects after getting the jab which . On day 21, 1 day after starting physical therapy, he developed acute bilateral arthritis in his ankles, with mild enthesitis in his right Achilles tendon, without rash, conjunctivitis, or preceding diarrhoea or urethritis. Every effort has been made to ensure that all information is accurate, up-to-date, and complete, but no guarantee is made to that effect. Some information may be out of date. Rashes in Tamsulosin, how severe and when it was recovered? According to the federal Vaccine Adverse Event Reporting System (VAERS) [1], there were 21 deaths this flu season after 180+ million flu vaccines, a rate of 1 death per 9,000,000 vaccinations. The Centers for Disease Control (CDC) recommends that you have the vaccine even if you have had a COVID-19 infection and recovered. Clinical Imaging. Jackson and Noren said SIRVA attorneys advised that their injuries would not likely be compensated under the CICP. People can develop reactive arthritis after COVID-19. However, both mRNA vaccines have been linked to cases of myocarditis, or heart inflammation, in men aged 30 and younger after their second dose of COVID vaccine. The study found that some patients reported an all-body rashmedically known as a morbilliform rashoften . "We're certainly not seeing a pandemic of SIRVA" with COVID vaccines, D.J. In most individuals, the symptoms slowly decrease over time. Houston, TX - Feb 11, 2021. Some patients may experience side effects after vaccination, but these are typically mild and go away in a few days. People with inflammatory or autoimmune arthritis may be at greater risk of contracting COVID-19 and developing more severe symptoms than others. COVID-19 vaccines produce an antibody reaction that protects you from the disease. In some circumstances, however, your surgeon may recommend waiting for two or three days after vaccination to have your surgeryjust to ensure that you have no side effects. Case presentation: A 50-year-old Thai male began experiencing left shoulder pain about 3 hours following a COVID-19 vaccination. Resurrected Supernova Provides Missing-Link, Bald Eagles Aren't Fledging as Many Chicks, Ultracool Dwarf Binary Stars Break Records, Deflecting Asteroids to Protect Planet Earth, Quantum Chemistry: Molecules Caught Tunneling, Shark from Jurassic Period Highly Evolved. A new Northwestern Medicine study has, for the first time, confirmed and illustrated the causes of these symptoms through radiological imaging. Here, we report a rare case of an 83-year-old woman who was diagnosed with calcification in her left shoulder one year ago and developed calcific tendinitis after receiving an mRNA vaccine for COVID-19 (Pfizer-BioNTech). The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). This is to ensure that any problems you may experience after your procedure are not mistaken for side effects of the vaccine. So in our paper, we discuss the various types of musculoskeletal abnormalities that radiologists should look for and provide imaging examples.". Both Noren and Jackson said their insurance covers their medical bills, and they both feel relieved that they can still work, but they're frustrated that there's no federal protection for SIRVA related to COVID-19 vaccines. Shoulder injury related to vaccine administration ( SIRVA) is " shoulder pain and limited range of motion occurring after the administration of a vaccine intended for intramuscular administration in the upper arm . Unilateral Axillary Adenopathy in the Setting of COVID-10 Vaccine. pain and swelling in the joints, especially the large joints of the legs, such as the ankles and knees, symptoms that affect only one side of the body, performing strengthening exercises, which prevent muscle wasting. Although he was healthy before he received the COVID-19 vaccine, he began having symptoms of RA 4 weeks after his final vaccination. Opens in a new tab or window, Share on LinkedIn. We link primary sources including studies, scientific references, and statistics within each article and also list them in the resources section at the bottom of our articles. Gahan, a clinical psychologist in Shrewsbury, United Kingdom, hasn't . Bancsi A, Houle SKD, Grindrod KA. If you've received monoclonal antibodies, you must wait 90 days after recovering from COVID-19 to receive the vaccine. All information is observation-only. After adjustment for baseline characteristics, the study found that the hazard of aortic aneurysm increased by 2.24-fold (95% CI=2.02-2.49) during a 30-day risk window following the treatment episode. The former Cowboys' star, who was picked in the first round of the 2015 draft, now claims he can't "run or jump" because of his injuries from playing football. The site is secure. Northwestern University. Although the mechanism of flare is not known, one could speculate that one of these components might have had non-specific adjuvant effect, or there could have been molecular mimicry between the viral spike peptides and the patient's self-peptides, activating a flare. "Radiological images confirm 'COVID-19 can cause the body to attack itself': Imaging illustrates severity, long-term prognosis of COVID-19-related muscle, joint pain." We would never know about this side effect (or others) but for publications like yours." COVID-19 infection itself has been associated. You can use the study as a second opinion to make health care decisions. Published by Oxford University Press. Get the latest science news in your RSS reader with ScienceDaily's hourly updated newsfeeds, covering hundreds of topics: Keep up to date with the latest news from ScienceDaily via social networks: Tell us what you think of ScienceDaily -- we welcome both positive and negative comments. Reactive arthritis can occur after various infections, even if joint pain was not a symptom during the initial illness. He or she may also recommend waiting for a period of time after vaccination.Your doctor can answer any questions you may have about the timing of corticosteroid injections and COVID-19 vaccination. This is considered an overuse injury caused by repetitive hand or wrist motion. Arthritis after COVID-19 is a potential complication of the illness. But it's not clear if the vaccine itself causes the ear ringing. 8600 Rockville Pike For patients presenting with unremitting shoulder pain and reduced shoulder range of motion after recently receiving a SARS-CoV-2 vaccine, clinicians should consider SIRVA in their differential diagnosis, along with . "We've realized that the COVID virus can trigger the body to attack itself in different ways, which may lead to rheumatological issues that require lifelong management," said corresponding author Dr. Swati Deshmukh. Factors that may contribute include: COVID-19 vaccines can also cause temporary side effects that feel similar to those of arthritis or RA, such as: These effects usually last a few days but can last up to several weeks. Kristina Fiore, Director of Enterprise & Investigative Reporting, MedPage Today Opens in a new tab or window, Visit us on LinkedIn. READ MORE: Covid pneumonia symptoms: Five . While the connection between tinnitus and the Covid vaccine are not yet understood: The British Tinnitus Association has labeled tinnitus a rare side effect of the vaccine. MNT is the registered trade mark of Healthline Media. Nonsteroidal anti-inflammatory drugs are the first-line treatment when reactive arthritis starts. Many patients who have had the virus have a positive antibody test. This included injuries to the soft tissues of the shoulder as well as injuries to bone and joint. Fatigue (feeling of tiredness): 25 people, 13.89%, Mobility Decreased (ability to move is reduced): 17 people, 9.44%, Arthritis (form of joint disorder that involves inflammation of one or more joints): 16 people, 8.89%, Muscle Aches (muscle pain): 15 people, 8.33%, Hypoaesthesia (reduced sense of touch or sensation): 14 people, 7.78%. Three months is a . However, there are less frequent symptoms you probably wouldn't expect that follow some people both during the illness and long after recovery. If you use this eHealthMe study on publication, please acknowledge it with a citation: study title, URL, accessed date.

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