To make a tincture, a plant is covered in alcohol and allowed to infuse for a certain length of time. During this period, the plant’s constituents will become extracted from the plant. The plant and the liquid are then separated by a filter and the tincture is the remaining liquid product.

At the clinic, I currently carry 10 tinctures, some single herb tinctures and some are combinations. I purchased them all from Perfect Herbs, a Toronto based company made up of a group of Registered Herbalists and Naturopathic Doctors. The company was started by one of my former teachers, Dr. Chris Pickrell, ND, who also happened to be my interviewee in one of my first blog entries! Perfect Herb’s mission is to keep herbs accessible, affordable, and sustainable and they aim to provide the safest, purest, and highest quality herbal products.

My tinctures are available in the following sizes and prices (tax included):

100mL – $21

250mL – $41

500mL – $66

Here is a list of the 10 tinctures currently available*:

  1. Kava Kava (Piper Methysticum– Kava is a nervine, anxiolytic and mild euphoric. It is an excellent choice for anxiety and insomnia.
  2. Withania Somnifera (Ashwagandha) – An excellent herb to help with anxiety and stress. Used often among people with fatigue, nervous exhaustion and chronic inflammatory diseases. Also considered a mild libido tonic.
  3. Vitex Agnus Castus (Chasteberry) – Vitex is widely used to treat irregular menses and PMS. Interestingly, it also helps to increase nighttime melatonin production by up to 60%, so can help support sleep as well. Often used among patients with fertility issues as well, since Vitex is indirectly progesterogenic.
  4. Glycyrrhiza glabra (Licorice Root) – Licorice is a popular adaptogen among NDs, as it is great at helping the body in times of stress. It can be good for people with low blood pressure. It is also an anti-inflammatory, anti-viral and a demulcent, so is good for bronchitis, upper respiratory tract infections and post-viral cough.
  5. Angelica Sinesis (Don Quai)This is generally considered a Traditional Chinese Medicine (TCM) herb. From a TCM perspective, it builds blood and regulates menses of deficiency. It can support the endocrine system and is also considered an adaptogen (an herb that helps with stress).
  6. Hypericum Perforatum (Saint John’s Wort) – This herb is most commonly used to help treat depression. However, it is also both an anti-viral and anti-inflammatory herb, and can be used topically for herpes lesions. In terms of mood, it can help treat seasonal affective disorder, irritability and anxiety from menopausal changes, depression or general melancholy.
  7. Schisandra Chinesis (Schisandra Berry) – In TCM theory, this is one of the only herbs that enters into all 12 meridians. It is good for people with a weakened vitality, loose stool and diarrhea and skin conditions. Based on it’s constiuents it is hepatoprotective, meaning it helps to protect the liver.
  8. Herbal Antibiotic – An herbal combination that can quickly clear the body of acute or ongoing infections, such as colds, flus and seasonal infections.
  9. Bitter’s Carminative Digestive – A tasty herbal combination that can be taken before or after a meal to help support overall digestion.
  10. Profound Immune – A blend of both herbs and mushrooms that support the immune system at the deepest level. This combination can help the body to prevent infections and rebuild the immune system.


*Please note that tinctures are only available to new or existing patients. When I sell a tincture I need to make sure that it is both safe and indicated for the person who is buying it (ie doesn’t interact with any current medications or supplements they are on, relevant to their medical condition, proper teaching about safe dosages, etc).




Dr. Madeleine’s top 5 low-or-no-cost summer activities!

With the first day of summer being right around the corner, and the weather having recently turned warm here in Toronto, I thought I would do a post about my favourite summer activities! Narrowing down the list is difficult, because Toronto in the summer is just bursting at the seams with fun things! However, I have nailed down what, for me, are the ones I come back to year after year….

So here you go folks – Dr. Madeleine’s top 5 low-or-no-cost summer activities:

  1. Go to the beach! We are so lucky to live in a city that is on the water. There are many beaches to choose from, however, my favourites are Woodbine beach and Ward’s island beach. And yes, you can swim in the water. Just check this site before you head out, to confirm! It is updated daily, but note: it’s best to avoid swimming 2 days after a storm (the website is 24 hours behind because it takes a day to grow the cultures for the quality tests). If you have never been to the island: GO. GO NOW!! It’s a magical, mystical, beautiful place. The ferry ride is so fun, and really inexpensive. Pack food and water and you will barely have to spend any money at all (although, I do love going to the Island Cafe). For all beaches, if you can somehow go on a weekday instead of a weekend, it’s nice to beat the crowds.
  2. Farmer’s Markets! There are Farmer’s Markets all across Toronto, on many different days of the week. They often have musicians playing, activities for kids, and of course lots of locally sourced, organic food. Nothing can beat an Ontario strawberry this time of year, I know me and my partner have been devouring them of late. I love picking up a bag full of fresh food, coming home and making a delicious, spontaneous, nourishing meal.
  3. Outdoor Movies! You guys! What is more romantic than an outdoor movie? Bring a date, bring yourself, bring your dog, bring some snacks, bring a big comfy blanket, maybe some all natural bug spray and watch a movie under the trees. They are speckled all over the city, so you’re sure to find one not too far from you!
  4. Shakespeare in the Park!! [I am seriously getting more excited with each item on this list]. I am a big fan of live theatre. I don’t go enough, but it holds a very special place in my heart, having been a Musical Theatre major in high school and coming from a family that loves and supports the arts. Shakespeare in the Park consistently casts incredible actors. This year they are doing Romeo and Juliet + A Midsummer Night’s Dream. It’s a pay-what-you-can event, and yes, you can bring snacks (is it obvious yet that I love snacks?). I have noticed that this event has gotten super popular in the last few years, so if you want a good seat, I would get there at least an hour early. Make sure you bring a comfy cushion or blanket to sit on too!
  5. Go see an ND! Okay, okay – shameless plug. But I wouldn’t say it if I didn’t believe it. Why wait until the hecticness of fall to plan out your health goals? Plus, taking the time to just focus on yourself, and sit in a room with someone who provides you the wide open space to just be you feels GOOD. And although seeing an ND may not be free, many people have it covered under extended health plans. I also offer a sliding scale for anyone who needs it. Come on in and let’s make this summer all about you being your most powerful, radiant self, deal?

See you at the beach!

Dr. Madeleine Elton, ND


Can fish oil help with dysmenorrhea (aka painful periods)?



Dysmenorrhea is pain and cramping in the lower abdominal region during a woman’s menstrual cycle. There are two types of dysmenorrhea: primary or secondary. In primary dysmenorrhea there is pain with no organic disease present and this form starts six months to two years after menarche (a woman’s first period). Secondary dysmenorrhea is pain with menses that is associated to a disease process. This form starts typically when women are in their twenties and becomes increasingly worse with age. Secondary dysmenorrhea can be associated to a range of different disorders, including endometriosis, uterine polyps, leiomyoma (fibroids), ovarian cysts, and many more. Although dysmenorrhea is not a life threatening disorder in and of itself, it impacts a woman’s quality of life greatly and is the most common gynecological problem among menstruating women. Numerous studies have also shown that women who suffer from dysmenorrhea have higher rates of absenteeism from school or work, which can be correlated to lost societal productivity.


The standard first-line allopathic treatment of dysmenorrhea is the use of NSAIDs. Another common course of treatment is the use of oral contraceptives. If neither of these treatment protocols work there is additional inquiry required to rule out secondary dysmenorrhea. Even if secondary dysmenorrhea is identified, NSAIDs and oral contraceptives are commonly prescribed. Like any medication, these two are not without their associated risks. Of particular concern is peptic ulcers and thus internal bleeding in relation to the use of NSAIDs. A low but serious risk factor associated with the use of oral contraceptives that contain estrogen is the development of blood clots. This risk further increases among women who smoke cigarettes.


While conventional medicine uses anti-inflammatory medication, an ND may look at reducing overall inflammation in the patient’s body through diet. Often this begins with an elimination diet, to try and identify whether there is any food that aggravates the patient. This may extend into more permanent elimination of common triggers, such as dairy or gluten. Encouraging the patient to avoid sugar, alcohol and smoking would also be critical to decrease an inflammatory state. Other dietary approaches with varying levels of evidence that may help with dysmenorrhea include regular breakfast habits, aspartame ingestion and low fat vegan diets. Nutritional supplements that also have research to back up their efficacy in treating dysmenorrhea include magnesium, thiamine, vitamin E, iron, niacin, flavonoids, ginger root and of course omega-3 fatty acids. According to a 2001 Cochrane Review on herbal and dietary therapies for dysmenorrhea, the authors concluded that based on all available evidence, vitamin B1 and magnesium both may have benefits in the reduction of pain with dysmenorrhea.

An ND may also use some or all of the following modalities: hydrotherapy, homeopathy, lifestyle change counseling, botanical medicine and acupuncture.

For example, with hydrotherapy, an ND may recommend the use of hot compresses to relax the muscles, hot sitz bath as an analgesic and constitutional hydrotherapy for increased circulation and cellular metabolism.

Many different botanicals could also be used to help with dysmenorrhea. Desirable actions for these herbs would be antispasmodics, nervines, diuretics, uterine tonics and hormonal normalizers. For example, a common tincture prescription for people suffering from dysmenorrhea is Viburnum prunifolium (antispasmodic), Scutellaria lateriflora (nervine and antispasmodic) and Cimicifuga racemosa (anispasmodic, anti-inflammatory, nervine).

A very big lifestyle recommendation would be for patients who suffer from dysmenorrhea to regularly exercise. Exercise can have the effect of lowering the incidence of dysmenorrhea through mediating stress and hormones.

Finally, the use of acupuncture can help to decrease dysmenorrhea. For example, from a Traditional Chinese Medicine perspective, dysmenorrhea is a common symptom in patients who present with liver blood stasis. Causes of this are Qi stagnation, cold and heat. Acupuncture points that may be beneficial include, but are not limited to, stomach 36 (tonifies Qi), liver 3 and liver 4 (promotes smooth flow of liver Qi).


Essential fatty acids act as precursors to prostaglandins, prostacyclins, thromboxanes and leukotrienes. These substances have critical influences on immune function, smooth muscle function, platelet aggregation and inflammation. Omega-3 fatty acids are responsible for 3-series prostaglandins while omega-6 fatty acids are responsible for 1-series prostaglandins. Generally speaking, the western diet is lacking in omega-3 fatty acids as it is not present in a lot of our common dietary oils and cold water fish and linseed oil are not a part of the typical diet. On the other hand, it is common to find omega-6 fatty acids in dietary oils. If the body receives a higher amount of one of these, it inhibits the metabolism of the other.

Before a woman menstruates, she has a progesterone withdrawal. At this time there is a cascade of prostaglandins and leukotrienes in the uterus. The ensuing inflammatory response is responsible for cramps, nausea, vomiting, bloating and headache. The prostaglandins that are produced could be 3-series or 1-series prostaglandins. Omega-3 prostaglandins (3-series) are less potent than the ones produced by omega-6 fatty acids (1-series). If a woman produces less potent prostaglandins the result could be less myometrial contraction, vasoconstriction, ischemia and pain. Thus, if a woman is taking an omega-3 fatty acid supplement, there is a higher likelihood that she will experience less dysmenorrhea based on the above information. This may be more applicable to women with primary dysmenorrhea, but could potentially play at least a partial role for women with secondary dysmenorrhea, depending on the cause.


The author of this article examined studies that compared fish oils to placebo and other oils in the treatment of dysmenorrhea. Papers that looked at surveys and case reports were also included. The overarching theme was that, at least to some degree, supplementation with omega-3 fatty acids does decrease symptoms associated with dysmenorrhea. For example, in a 2011 research paper 120 women with dysmenorrhea were randomly divided into two groups. One group received 100mg/day of fish oil and the other group received ibuprofen. Both fish oil and ibuprofen provided pain relief among these women. In another study it was identified that fish oil with B12 appeared to have the greatest effect in pain reduction. Surveys that examined dietary habits among women of reproductive age also found that those who consume less fish appeared to be more likely to have dysmenorrhea. More studies that compare the intake of omega-3 fatty acids to standards first line conventional treatment of dysmenorrhea (ie NSAIDs or oral contraceptives) should be done in order to determine whether omega-3 fatty acids are in fact a comparable treatment.


Naturopathic Doctors will commonly prescribe fish oil to patients for a variety of conditions. Research has demonstrated its efficacy in relation to a variety of mental health conditions, alzheimer’s disease, autism, skin conditions such as eczema, coronary artery disease and rheumatoid arthritis. Outside of patients with fish allergies, the intake of omega-3 fatty acids is considered safe when taken up to 3.5 years. A common concern regarding the intake of fish oil is that it may increase one’s chance of bleeding. A 1992 study followed 365 patients over seven-years who took a daily fish oil supplement. These patients had ischemic heart disease, hyperlilipedmia or a strong family history of ischemic heart disease. The research found that there were no adverse effects. Of course, an ND must look at each patient as an individual and decide based on their entire picture whether fish oil is warranted and safe. However, based on the overarching lack of harms associated with the intake of fish oil, fairly accessible prices and significant potential overall health benefits, relating to dysmenorrhea and beyond, it appears that omega-3 fatty acid supplements, commonly in the form of fish oil, are an excellent supplement to prescribe to patients. Alternatively, encouraging patients to increase their intake of fish in the diet would also be advisable and patients could budget this into their weekly groceries spending as opposed to having to buy a supplement separately.


American Family Physician. Primary Dysmenorrhea. Retrieved from:http://www.aafp.org/afp/1999/0801/p489.html.

Barron, P. Hydrotherapy theory & technique. St James City, FL: Pine Island Publishers INC; 2003.

Dains, JE, Bauman, LC & Scheibel, P. Advanced health assessment & clinical diagnosis in primary care, 4th ed. St. Louis: Mosby; 2012

Deutch, B, Jorgensen, EB, Hansen, JC. Menstrual discomfort in Danish women reduced by dietary supplements of omega-3 PUFA and B12 (fish oil or sea oil capsules). Nutrition Research. 2000; 20: 621-631.

Deutch, B. Menstrual pain in danish women correlated with low n-3 polyunsaturated fatty acid intake. European Journal of Clinical Nutrition. 1995; 49: 508-516.

Gaby, A. Nutritional Medicine. Concord, NH: Fritz Perlberg Publishing; 2011.

HealthLink BC. Hormonal Birth Control: Risk of Blood Clots. Retrieved from: http://www.healthlinkbc.ca/healthtopics/content.asp?hwid=tw9278.

Hoffman, D. Medical Herbalism: The Science and Practice of Herbal Medicine. Rochester, V.T.: Healing Arts Press; 2003.

Kassam, N, Gowan, M. Fundamentals of Clinical Acupuncture. Toronto, ON: CCNM Press; 2009.

Mayo Clinic. Drugs and Supplements: Omega-3 Fatty Acids, Fish Oil, Alpha-Linoleic Acid. Retrieved from: http://www.mayoclinic.org/drugs-supplements/omega-3-fatty-acids-fish-oil-alpha-linolenic-acid/safety/hrb-20059372.

Melvyn, R, Werbach, MD. Textbook of Nutritional Medicine. Tarzana: C.A.: Third Line Press; 1999.

Moghadamnia, AA, Mirhosseini, N, Abadi, MH, Omranirad, A, Omidvar, SH. Effect of clupeonella grimmi (anchovy/kilka) fish oil on dysmenorrhoea. Eastern Mediterranean Health Journal. 2010; 16: 408-413.

Proctor, M, Murphy, PA. Herbal and dietary therapies for primary and secondary dysmenorrhea. Cochrane Database of Systematic Reviews. 2001: CD002124.

Prousky, J. Textbook of Integrative Clinical Nutrition. Toronto, ON: CCNM Press; 2012.

Sarris, J, Wardle, J. Clinical Naturopathy: An Evidence-Based Guide to Practice. Sydney, Toronto: Churchill Livingstone/Elsevier; 2010.

Saynor, R, Gillott, T. Changes in blood lipids and fibrinogen with a note on safety in a long term study on the effects of n-3 fatty acids in subjects receiving fish oil supplements and followed for seven years. Lipids. 1992; 27: 533-538.

Vojvodic, M, Young, A. 2014 Toronto Notes: Comprehensive Medical Reference and Review for the Medical Council of Canada Qualifying Exam Part 1 and the United States Medical Licensing Exam Step 2, 30th ed. Toronto, ON: Toronto Notes for Medical Students, Inc.; 2014.

Zafari, M, Behmanesh, F, Agha, Mohammadi A. Comparison of the effect of fish oil and ibuprofen on the treatment of severe pain in primary dysmenorrhea. Capsian Journal of Internal Medicine. 2011; 2: 279-282.


Female Pelvic Exams


With International Women’s Day this month, I thought now was a great time to write a blog post about female pelvic exams. I come to realize, time and time again, that many people are misinformed about what a Naturopathic Doctor can offer as part of our services. Although this will vary from province to province, in Ontario, Naturopathic Doctors are able to perform female pelvic exams. Not all NDs have the clinic setup or clinical focus that will allow for this examination, so always ask an ND if they provide this service before you book an appointment.

While studying at the Canadian College of Naturopathic Medicine (CCNM), I received excellent training on how to perform this exam. After passing a series of practical competency examinations, first on plastic pelvic simulators, then on paid models, we were then required to complete a certain number of pelvic exams on patients during our final clinical year. Fun fact, during my second year of the program, I was actually one of the paid gynecological models! So not only have I been tested in my skills, I have also had the opportunity to experience the vulnerability of being the one on the examination table many times. In addition to the training I had at CCNM, I also was trained in female pelvic exams when I was working as a Public Health Nurse. I did this through the McMaster University Well Women Workshop training program. What’s especially neat about this training, is that the models give you real time feedback on your technique. My model, this amazing woman who has been helping health care providers become more proficient in this sensitive and important skill, actually reached down and put her hand on my hand while I was inserting the speculum, so that she could show me the exact position that allowed her to feel optimal comfort.

Okay, so enough background information, let’s get to the nitty gritty. What do I even mean when I say female pelvic exam anyway?

First, I will spend time asking you about your health history. We will determine what parts of the pelvic exam are required for you, if any. For example, the Ontario Cervical Screening Program recommends that women who are or have been sexually active have a Pap test every 3 years starting at age 21. You will also be able to share with me any fears or concerns you have regarding this exam. We will be sure that you feel comfortable and empowered at all times.

For the actual exam, you will be in a private room at the clinic where I work on the Danforth. I will take good care to explain to you everything you should expect, and let you know that you can ask me to stop the exam at any time for any reason. Once we begin, there is first an external examination of the vulva for both a visual and physical assessment. The second part is the Pap test and/or a swab for cultures. The final part is a bimanual examination (where two fingers, wearing a medical glove, are inserted into the vagina) where I will assess the health of your uterus and ovaries. I will explain each step before I begin, and you will be in control the entire time. At the end of the exam I will test the pH of your vaginal fluid, as a part of an overall assessment of vaginal health.

Here are some FAQs that you may be curious about:

Q: What can a Naturopathic Doctor test for when it comes to the female pelvic exam?

A: Naturopathic Doctors can perform pap smears, which collect cells from the cervix. The sample is sent to the laboratory where it is examined for any abnormal cells which may indicate pre-cancer or cancer of the cervix. Naturopathic Doctors can also swab for Bacterial Vaginosis, Candida and Trichomonas.

Unfortunately, at this time, Naturopathic Doctors cannot swab for sexually transmitted infections, such as gonorrhea or chlamydia.

Q: Is this covered under OHIP?

A: Naturopathic Care is not covered under OHIP. Many extended health insurance plans cover the cost of the appointment when you see a Naturopathic Doctor. The pap test and/or swab is at an additional cost. Please feel free to contact me for details.

Q: Why would I see an ND for this instead of my Medical Doctor?

A: There could be many reasons for this, but at the end of the day, you should see whoever feels like the right fit for you and your health needs. Sometimes people seek out a Naturopathic Doctor for female pelvic exams as we can spend more time with the patient, explaining the process and ensuring you feel comfortable. We also strive to make it a very educational experience, where you leave feeling empowered about the knowledge you have gained in regards to your health and your body.

I hope this blog post has been interesting and informative for you! Feel free to reach out if you have any questions, or book in an appointment to learn more about your pelvic health.

Yours in Health,

Dr. Madeleine Elton, ND


Fertility Awareness Method

Photo by Catherine McMahon

Photo by Catherine McMahon

This month instead of doing a written blog post, I decided to concentrate my efforts on a video instead! I learned about the Fertility Awareness Method (FAM) about 10 years ago when I wanted to get off of hormonal birth control (but still avoid pregnancy) and learn more about my body. I was originally taught, via one-on-one lessons, by Amy Sedgwick, back when the Red Tent Sisters was a physical store on the Danforth!

I charted my cycles for years. Not only did I become very familiar with when I ovulate and when I could expect my period, I also started to notice emotional patterns I had each month. I noticed physical changes that my body would have during certain parts of my cycle. I felt like I understood my body on a level I had never known.

To learn FAM, and to practice it with a full understanding, takes some time, dedication and patience. My video, which can be found on my Facebook page, is a very basic explanation of FAM. I just wanted to provide people with an opportunity to get a sense of what it is, but this is not the be-all and end-all, this is just the beginning. Enjoy!



5 Ways to Manage the Symptoms of Seasonal Affective Disorder


Photo by: Viktoria Hall-Waldhauser

Ah, winter time. The days are darker, the air is colder and a lot of us feel, sort of….”meh”. One potential reason for this change in mood is Seasonal Affective Disorder (or SAD). SAD is defined as “recurrent depressive episodes during autumn and winter alternating with nondepressive episodes during spring and summer”. Symptoms include low energy, irritability, overeating and weight gain. Symptoms generally begin in November and last, on average, for five months. Like with any condition, there are a range of possible causes for SAD.  It can be a mix of climate, psychological and sociocultural factors and genetic vulnerability. It also seems to disproportionately affect more women than men, and is more common among younger people.

Here are five things you can do to help manage SAD symptoms:

  1. Bright Light Therapy: These bright lights can be purchased at a variety of stores and the general recommendation is 10,000 lux (light intensity) for 30 minutes daily in the morning for up to 6 weeks. The light helps to alter circadian rhythms and modulate serotonin and catecholamines. Potential side effects include headache, eye strain, nausea and agitation. UBC has some good information on how to get a light device.
  2. Cognitive Behavioural Therapy (CBT): CBT has been shown to improve SAD symptoms, either on it’s own or alongside light therapy. Many therapists and other health care providers offer CBT services. Alternatively, there are options for working through CBT exercises online, such as with moodgym.
  3. Vitamin D: Many Canadians find themselves deficient in Vitamin D during the winter months. With the sun being further away from the earth and our skin being regularly covered with multiple layers of clothing, it’s hard to get much sun exposure. Improved Vitamin D status has been linked to improvement in depression scale scores.
  4. St. John’s Wort: This herb, also known as Hypericum, has a long history of use when it comes to depression. It can be consumed in a tea, tincture or pill form. Finding the dose that is right for you is important, as well as making sure this herb does not interact with any medications you may be taking.
  5. Melatonin: This hormone is produced by the pineal gland and helps to regulate sleep. It’s synthesis is triggered by darkness. Abnormal melatonin synthesis may be a cause of SAD. Supplementing with melatonin may help to manage SAD symptoms.

This list does not include the basic pillars for health, which are diet, exercise, stress management and sleep. These pillars should always be addressed first before beginning any sort of treatment. Seeing a Naturopathic Doctor can also help you to discover whether there is a dietary or hormonal component to your mood changes. I invite you to book a free 15 minute appointment with me, so that you can begin to feel good this winter and beyond!

Yours in Health,

Dr. Madeleine Elton, ND



Ferri, F. Ferri’s Clinical Advisor 2018.

Goth, FM 3rd, Alam, W, Hollis, B. Vitamin D vs broad spectrum phototherapy in the treatment of seasonal affective disorder. J Nutr Health Aging. 1993;3(1):5-7.

Leppamaki S, Partonen T, Vakkuri O, et al. Effect of controlled-release melatonin on sleep quality, mood, and quality of life in subjects with seasonal or weather-associated changes in mood and behaviour. Eur Neuropsychopharmacol 2003;13:137-145.

Martinez B, Kasper S, Ruhrmann S, Moller HJ. Hypericum in the treatment of seasonal affective disorders. J Geriatr Psychiatry Neurol 1994;7:S29- S33.

Ravindran et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder Section 5. Complementary and Alternative Medicine Treatments. Can J Psychiatry. 2016 Sep; 61(9):576-587.

Rohan, K, Meyerhoff, J, Ho, SY, Evans, M, Postolache, TT, Vacek, PM. Outcomes one and two winters following cognitive-behavioral therapy or light therapy for seasonal affective disorder. Am J Psychiatry. 2016 Mar 1;173(3):244-51.


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