![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 87 to 111 of 8406. Go back in thread:
Posted by pharmrep on August 20, 2002, at 11:42:31
In reply to Re: Citalopram pharmacology -Dr. Dave, posted by Ritch on August 20, 2002, at 9:37:03
NO.....10mg Lex is 40mg of Celexa...trust me.
Posted by Anyuser on August 20, 2002, at 12:17:02
In reply to Re: Citalopram pharmacology -Dr. Dave » Ritch, posted by pharmrep on August 20, 2002, at 11:42:31
The prescribing info recommends 10mg, period, including elderly patients and those with impaired livers or kidneys. It is interesting to note that the prescribing info says there seems to be no benefit to 20mg over 10mg.
I'm curious, why even bother to manufacturer 5mg pills? The 10 mg pills are scored. Has any testing been done on the 5mg dose?
Posted by Mr.Scott on August 20, 2002, at 13:00:21
In reply to Re: Citalopram pharmacology -Dr. Dave » Ritch, posted by pharmrep on August 20, 2002, at 11:42:31
I am reposting this because even though I haven't picked out anything in your posts that cross any lines you are by definition biased. If your not here for help with a mental disorder it's kind of silly that your here at all. Yes for many, Lexapro will work as an antidepressant, and for some it will not, and other still will have problems with it entirely.. To think it will be light years ahead of anything currently available is preposterous. Everyone is different and your studies with 10,000 patients by doctors who are paid in grants and whose funding has been "underwritten in educational disguise" have consistently failed to elucidate the whole picture on any of these meds when used on a given individual. I would be a no see doc if I was one. Donuts for my office staff and samples for my patients, otherwise... well anyways my post below is what Forest's real goal is. If a few suffering people can benefit than great.
Citalopram is the #1 most used AD in the world
Forest has the marketing rights to Citalopram in the US under Celexa, but not in Europe where it actually is the number 1 prescribed antidepressant. In Europe and all other non-us companies, citalopram is owned by various other companies.
Forest will have full international rights to Lexapro and will launch a campaign to convert the entire world on Citalopram (Celexa and other names) to the new improved Leaxapro. Much more marketshare and money.
Believe me when I tell you that there is not a single person in the pharmaceutical industry who cares about you and your depression as much as they care about you and your money. Their motivations are always 100% based on bottom line revenue. Don't ever think for a second they have any other motivation whatsoever. Altruism is not welcome in this industry. Thats what Church on Sunday is for...
Scott
Posted by Ritch on August 20, 2002, at 13:10:54
In reply to Re: Citalopram pharmacology -Dr. Dave » Ritch, posted by pharmrep on August 20, 2002, at 11:42:31
> NO.....10mg Lex is 40mg of Celexa...trust me.
PharmRep,
I wished somebody would do receptor affinity profiling for r- and s- citalopram separately. If the r- isomer has little affinity for the serotonin reuptake transporter, it (the r-isomer) possibly could have an increased affinity for other receptors involved with side effects. I did find it interesting in the micromedex link posted a while ago that the half-life of s-citalopram is about 22 hrs and that the half-life of s+r-citalopram is about 35 hrs. (If that is inaccurate-please somebody correct me).
thanks,Mitch
Posted by pharmrep on August 20, 2002, at 14:40:38
In reply to Question re dose » pharmrep, posted by Anyuser on August 20, 2002, at 12:17:02
> The prescribing info recommends 10mg, period, including elderly patients and those with impaired livers or kidneys. It is interesting to note that the prescribing info says there seems to be no benefit to 20mg over 10mg.
>
> I'm curious, why even bother to manufacturer 5mg pills? The 10 mg pills are scored. Has any testing been done on the 5mg dose?no...not yet...10 is the starting and maintenance dose...20 if 10 looks a little "light." What do you mean 20mg no benefit? where did you read this?
Posted by pharmrep on August 20, 2002, at 14:52:48
In reply to Hey Pharm-rep, posted by Mr.Scott on August 20, 2002, at 13:00:21
> I am reposting this because even though I haven't picked out anything in your posts that cross any lines you are by definition biased. If your not here for help with a mental disorder it's kind of silly that your here at all. Yes for many, Lexapro will work as an antidepressant, and for some it will not, and other still will have problems with it entirely.. To think it will be light years ahead of anything currently available is preposterous. Everyone is different and your studies with 10,000 patients by doctors who are paid in grants and whose funding has been "underwritten in educational disguise" have consistently failed to elucidate the whole picture on any of these meds when used on a given individual. I would be a no see doc if I was one. Donuts for my office staff and samples for my patients, otherwise... well anyways my post below is what Forest's real goal is. If a few suffering people can benefit than great.
>
> Citalopram is the #1 most used AD in the world
>
> Forest has the marketing rights to Citalopram in the US under Celexa, but not in Europe where it actually is the number 1 prescribed antidepressant. In Europe and all other non-us companies, citalopram is owned by various other companies.
>
> Forest will have full international rights to Lexapro and will launch a campaign to convert the entire world on Citalopram (Celexa and other names) to the new improved Leaxapro. Much more marketshare and money.
>
> Believe me when I tell you that there is not a single person in the pharmaceutical industry who cares about you and your depression as much as they care about you and your money. Their motivations are always 100% based on bottom line revenue. Don't ever think for a second they have any other motivation whatsoever. Altruism is not welcome in this industry. Thats what Church on Sunday is for...
>
> Scott
> *** Sorry you feel that way...I am only trying to correct incorrect info givin, and add what I can...Why to you dislike Forest...you certainly dont know Howard Soloman and his story (re: his son). And Forest is definitely not promoting the switching of anybody who's med is working. If a patient is not getting what they want from their med...Lexapro might help. But there is no benefit to the company for changing from Celexa to Lexapro, so why say that? Does it make sense for a company to offer a new/unproved product to the public 3 yrs before the old one expires, or to offer it at a lesser price. I know it might be hard to believe, but Forest actually does have the patients best interests in mind, that is why Lexapro is being offered...it is a better product.
Posted by Anyuser on August 20, 2002, at 14:57:57
In reply to Re: Question re dose, posted by pharmrep on August 20, 2002, at 14:40:38
From Lexapro.com prescribing info: http://www.lexapro.com/prescribing_information/lexapro_pi.pdf, which says, "The recommended dose of Lexapro is 10mg once daily. A fixed dose trial of Lexapro demonstrated the effectiveness of both 10mg and 20mg of Lexapro, but failed to demonstrate a greater benefit of 20mg over 10mg."
Posted by pharmrep on August 20, 2002, at 15:13:03
In reply to Re: Citalopram pharmacology -Dr. Dave » pharmrep, posted by Ritch on August 20, 2002, at 13:10:54
> > NO.....10mg Lex is 40mg of Celexa...trust me.
>
> PharmRep,
>
> I wished somebody would do receptor affinity profiling for r- and s- citalopram separately. If the r- isomer has little affinity for the serotonin reuptake transporter, it (the r-isomer) possibly could have an increased affinity for other receptors involved with side effects. I did find it interesting in the micromedex link posted a while ago that the half-life of s-citalopram is about 22 hrs and that the half-life of s+r-citalopram is about 35 hrs. (If that is inaccurate-please somebody correct me).
>
>
> thanks,
>
> Mitch** hi Mitch...look this one up...it is a study that compares r-citalopram, s-citalopram and celexa (which is both combined). This is proof that Lexapro is more than just 1/2 of Celexa.
c. Sanchez, H. Loft, SA Montgomery Pharmacol Toxicol May 2001; 88(5): 282-286
PS Celexa half-life is 35hrs...Lexapro has a range of 27-32.
Posted by dr. dave on August 20, 2002, at 15:22:46
In reply to Re: Question re dose » pharmrep, posted by Anyuser on August 20, 2002, at 14:57:57
The statement '10mg Lex is 40mg Celexa' doesn't make any sense. Let's get down to the science here - '10mg lex' is 10mg of s-citalopram. '40mg Celexa' is 20mg s-citalopram plus 20mg r-citalopram. That's different. A study has been presented claiming 10mg Lexapro is as effective as 40mg Celexa - but Jack Gorman in his meta-analysis of the research states that this study was too small to demonstrate differences in efficacy. The result of one small trial is not necessarily the complete and absolute truth.
Is the separation expensive? A slow-moving bed plant required to separate stereoisomers costs upward of $5 million. To me, that's expensive.
Where do I get my info? From the published studies, which I have looked through thoroughly, and from a knowledge of pharmacology from studying at Cambridge University.
The studies SUGGEST certain things, but are very very far from demonstrating them conclusively. Statistical significance of difference is inconsistent across the studies. Lexapro will certainly not be cheaper than generic citalopram which is available in Europe to the best of my knowledge.
Although r-citalopram has some affinity to histamine (not 'histomine') receptors this does not mean it is 'inhibiting s-citalopram'. You cannot inhibit a molecule, you can only inhibit a process - which process involving s-citalopram is the r-citalopram/histamine receptor interaction inhibiting?
The whole marketing of this drug seems to be based on sloppy science. I have no problem with Celexa, I prescribe it all over the place, but raising desparate people's hopes with woolly and wishful thinking I object to.
I would be happy to discuss the shortcomings of any particular study on escitalopram that is publically available if we want to get into the science of it.
Posted by pharmrep on August 20, 2002, at 15:38:52
In reply to Re: Question re dose » pharmrep, posted by Anyuser on August 20, 2002, at 14:57:57
Good observation. In week 7 (of 8wk study) 20mg which had showed an edge over 10mg wks 1-6, became = to 10mg. This was due to the tolerabilty of 20 being slighty less than 10, and a few patients dropped out. (this is called last observation carried forward.) All doctors know about this and take LOCF stats in consideration because that is what a real practice is like...if people stop taking their med due to tolerance issues, the "scores" will reflect that. Anyway, to make a long story short(er)...20mg is more effective than 10mg. You can get the full study the FDA had and see for yourself. The graph is clear. (William Burke of Univ. of Nebraska did the study)
Posted by pharmrep on August 20, 2002, at 15:58:42
In reply to Citalopram pharmacology, posted by dr. dave on August 20, 2002, at 15:22:46
> The statement '10mg Lex is 40mg Celexa' doesn't make any sense. Let's get down to the science here - '10mg lex' is 10mg of s-citalopram. '40mg Celexa' is 20mg s-citalopram plus 20mg r-citalopram. That's different. A study has been presented claiming 10mg Lexapro is as effective as 40mg Celexa - but Jack Gorman in his meta-analysis of the research states that this study was too small to demonstrate differences in efficacy. The result of one small trial is not necessarily the complete and absolute truth.
>
> Is the separation expensive? A slow-moving bed plant required to separate stereoisomers costs upward of $5 million. To me, that's expensive.
>
> Where do I get my info? From the published studies, which I have looked through thoroughly, and from a knowledge of pharmacology from studying at Cambridge University.
>
> The studies SUGGEST certain things, but are very very far from demonstrating them conclusively. Statistical significance of difference is inconsistent across the studies. Lexapro will certainly not be cheaper than generic citalopram which is available in Europe to the best of my knowledge.
>
> Although r-citalopram has some affinity to histamine (not 'histomine') receptors this does not mean it is 'inhibiting s-citalopram'. You cannot inhibit a molecule, you can only inhibit a process - which process involving s-citalopram is the r-citalopram/histamine receptor interaction inhibiting?
>
> The whole marketing of this drug seems to be based on sloppy science. I have no problem with Celexa, I prescribe it all over the place, but raising desparate people's hopes with woolly and wishful thinking I object to.
>
> I would be happy to discuss the shortcomings of any particular study on escitalopram that is publically available if we want to get into the science of it.***I agree that the few studies out hardly represent the end-all-be-all of facts, but the 9 out now look promising. Pardon my appreviating...most of my posts I receive are like this, so I do it too. I met Dr. Gorman in June...he spoke for 1 hour and didnt hesitate on the research and efficacy findings. He said Lexapro has greater efficacy. As far as expense of isolating isomers...I dont know what the cost are to Forest...I only know that Lexapro will be less expensive to the patients than Celexa....and there is no generic for Celexa until late 2005 here or Europe. I may have oversimplified my histamine statement, but dont kill me for a typing error. (and it's Forest...not "Forrest")
Forest hasn't even begun any marketing yet, only a few studies are out to show efficacy, side-effect profile, drug to drug interactions, and tolerablity.... The FDA actually encourages isomer science. What dont you like? I would like to cover the studies with you since you have seen them....typing is too hard...what city are you in?
Posted by dr. dave on August 20, 2002, at 16:02:00
In reply to Re: Citalopram pharmacology -Dr. Dave » pharmrep, posted by Ritch on August 20, 2002, at 13:10:54
A study HAS been done on receptor affinity profiling for r- and s-citalopram separately. It is at http://www.cipralex.ch/pdf/poster/sobp_500.pdf
Note that the receptor affinities of r-citalopram are described as 'weak'.
I am reading that Lexapro doesn't cause somnolence - how does this fit with the fact that when study results have been combined, 1.9% of those on placebo complained of somnolence and 6% of those on Lexapro did? This is over three times as common. This gives you an idea of how the facts are being played around with here.
> > NO.....10mg Lex is 40mg of Celexa...trust me.
>
> PharmRep,
>
> I wished somebody would do receptor affinity profiling for r- and s- citalopram separately. If the r- isomer has little affinity for the serotonin reuptake transporter, it (the r-isomer) possibly could have an increased affinity for other receptors involved with side effects. I did find it interesting in the micromedex link posted a while ago that the half-life of s-citalopram is about 22 hrs and that the half-life of s+r-citalopram is about 35 hrs. (If that is inaccurate-please somebody correct me).
>
>
> thanks,
>
> Mitch
Posted by dr. dave on August 20, 2002, at 16:25:16
In reply to where's the love? » dr. dave, posted by pharmrep on August 20, 2002, at 15:58:42
OK, sorry about being snitty about spelling, and I stand corrected on 'Forest'.
I think the Gorman paper is weak. Jack Gorman is paid by Forest. He is also paid by Lundbeck. His paper has only managed to get published in a paper he edits himself. He is not independent of the significant financial pressures surrounding this issue.
Generic citalopram is already available in Europe from what I gather, having been launched in Israel earlier this year.
What city am I in? I'm in a hospital in a little village in the mountains of Wales, at least an hour from anything resembling a city!
> > The statement '10mg Lex is 40mg Celexa' doesn't make any sense. Let's get down to the science here - '10mg lex' is 10mg of s-citalopram. '40mg Celexa' is 20mg s-citalopram plus 20mg r-citalopram. That's different. A study has been presented claiming 10mg Lexapro is as effective as 40mg Celexa - but Jack Gorman in his meta-analysis of the research states that this study was too small to demonstrate differences in efficacy. The result of one small trial is not necessarily the complete and absolute truth.
> >
> > Is the separation expensive? A slow-moving bed plant required to separate stereoisomers costs upward of $5 million. To me, that's expensive.
> >
> > Where do I get my info? From the published studies, which I have looked through thoroughly, and from a knowledge of pharmacology from studying at Cambridge University.
> >
> > The studies SUGGEST certain things, but are very very far from demonstrating them conclusively. Statistical significance of difference is inconsistent across the studies. Lexapro will certainly not be cheaper than generic citalopram which is available in Europe to the best of my knowledge.
> >
> > Although r-citalopram has some affinity to histamine (not 'histomine') receptors this does not mean it is 'inhibiting s-citalopram'. You cannot inhibit a molecule, you can only inhibit a process - which process involving s-citalopram is the r-citalopram/histamine receptor interaction inhibiting?
> >
> > The whole marketing of this drug seems to be based on sloppy science. I have no problem with Celexa, I prescribe it all over the place, but raising desparate people's hopes with woolly and wishful thinking I object to.
> >
> > I would be happy to discuss the shortcomings of any particular study on escitalopram that is publically available if we want to get into the science of it.
>
> ***I agree that the few studies out hardly represent the end-all-be-all of facts, but the 9 out now look promising. Pardon my appreviating...most of my posts I receive are like this, so I do it too. I met Dr. Gorman in June...he spoke for 1 hour and didnt hesitate on the research and efficacy findings. He said Lexapro has greater efficacy. As far as expense of isolating isomers...I dont know what the cost are to Forest...I only know that Lexapro will be less expensive to the patients than Celexa....and there is no generic for Celexa until late 2005 here or Europe. I may have oversimplified my histamine statement, but dont kill me for a typing error. (and it's Forest...not "Forrest")
> Forest hasn't even begun any marketing yet, only a few studies are out to show efficacy, side-effect profile, drug to drug interactions, and tolerablity.... The FDA actually encourages isomer science. What dont you like? I would like to cover the studies with you since you have seen them....typing is too hard...what city are you in?
Posted by Anyuser on August 20, 2002, at 16:37:24
In reply to Receptor affinity profiles of s- and r-citalopram, posted by dr. dave on August 20, 2002, at 16:02:00
A recurring theme on this board is how to obtain reliable information about ADs. As among (1) scientific papers, both pre- and post- governmental approval, (2) clinical experience reported by practitioners, and (3) individual experiences, I would value (2) over (1) and (3). With respect to escitalopram, in the US there is no clinical experience and no individual experience. We patients, at the moment, are limited to the scientific papers. Most knowledgeable patients, and there are many on this board, know that drug applications are written by lawyers for lawyers. The prescribing information for Celexa, for example, is false and misleading with respect to the incidence of sexual side effects. I think a sensible attitude toward escitalopram is to be hopeful but sceptical. It might be enough of an improvement in reducing side effects to keep some number of patients on the drug longer.
You, on the other hand, as a practicing physician in the UK, have access not only to the scientific papers but also to the individual experience of Cipralex users. Moreover, you can get in the game and test the veracity of the scientific papers and the marketing raps by prescribing Cipralex. You say you prescribe Cipramil. You must have patients that suffer sexual side effects. Haven't any of such patients asked you to prescribe Cipralex instead? Let's say you have a patient who's been taking 40mgs of Cipramil and can't have an orgasm and tells you she is going off the drug. Why wouldn't you test Lundbeck's rap by writing a scrip for 10mgs of Cipralex and seeing how it worked for your patient? You don't have to rely on the papers, you can generate your own clinical experience. Why wouldn't you do so?
I'm not arguing the merits of escitalopram here. I don't know the truth. I'll be interested to hear what people say after they try it. You have a chance to try it on your patients and (apparently) choose not to, apparently in reliance meta-surveys. Why? I value your opinion now, but I think your opinion would carry even more weight if you were to say that you've tried Cipralex on your patients and they tell you it's better/worse/the same compared to Cipramil.
Posted by IsoM on August 20, 2002, at 16:51:15
In reply to Re: where's the love?, posted by dr. dave on August 20, 2002, at 16:25:16
It's already available in Sweden, Denmark, Germany, the Netherlands, Finland, Iceland, Israel, the Czech Republic & Australia.
(from http://www.lundbeck.com/investor/Reportsandpresentations/InterimReports/Interim_report_for_the_first_quarter_of_2002.pdf)Seropram was the name that citapolpram was marketed under in Austria, France, Greece, Italy & Spain. It seems that the patent for each name runs out at slightly different times in different countries.
Posted by Dinah on August 20, 2002, at 17:52:04
In reply to Re: where's the love?, posted by dr. dave on August 20, 2002, at 16:25:16
Sorry to interrupt with a tangent. But I just want to say how lovely I think your area is. I don't think there's anywhere in the world I love nearly as much as the mountains of Wales.
I'm envious.
Ok, tangent over.
Very sincerely,
Dinah
Posted by Ritch on August 20, 2002, at 22:16:19
In reply to Receptor affinity profiles of s- and r-citalopram, posted by dr. dave on August 20, 2002, at 16:02:00
Posted by pharmrep on August 20, 2002, at 22:29:21
In reply to Thanks for that pdf link! (nm) » dr. dave, posted by Ritch on August 20, 2002, at 22:16:19
Hi...did you find the Sanchez study done in US?...I saw the Euro one...it's a little different.
Posted by pharmrep on August 20, 2002, at 22:40:06
In reply to Re: where's the love?, posted by dr. dave on August 20, 2002, at 16:25:16
Come on Dr.D. Do you really think Dr. Gorman is going to ruin his reputation in his field and future for a paycheck today. How many studies are done where the Dr. didnt get some kind of "consideration" or grant for his/her time and effort? That would mean we cant trust any study at all. As far as credibility, if the FDA in the US is basing its decision on approving a drug with certain studies, you can bet they check out the credentials of the doctors, and parameters of the study before they put their stamp on it. I stand corrected...it appears that a generic will be available later this year on your side of the world, it wont be in the US until 2005...I see you are in Wales...I am in Southern California...guess we wont be meeting anytime soon (Ha Ha)
Posted by pharmrep on August 20, 2002, at 23:01:33
In reply to Re: Lexapro update, posted by katekite on July 31, 2002, at 10:13:30
Miss you...you ok? Lots of Lexapro talk going on.
Posted by pharmrep on August 20, 2002, at 23:03:56
In reply to Re: Lexapro update » pharmrep, posted by LLL on July 31, 2002, at 13:10:23
Miss you, you ok? Lots of Lexapro talk going on.
Posted by Ritch on August 21, 2002, at 8:53:02
In reply to Re: sanchez microdialysis study » Ritch, posted by pharmrep on August 20, 2002, at 22:29:21
> Hi...did you find the Sanchez study done in US?...I saw the Euro one...it's a little different.
I have it jotted down. I will need to go the library to dig it up (perhaps my pdoc has it). Since the earliest trial of Lexapro I would attempt would likely be early October I am in no big rush. I haven't even went through the European study just yet. I hear they have 5mg tabs. Are those scored? I would be quartering those into roughly 1.25mg chunks if I try the stuff.
Mitch
Posted by dr. dave on August 21, 2002, at 8:58:35
In reply to Knowledge » dr. dave, posted by Anyuser on August 20, 2002, at 16:37:24
This is a good point. I think my stance is that I shouldn't be changing my practice, particularly if it is an expensive change which will unavoidably reduce resources in some other area, until I have reasonable grounds for doing so, and I don't think that I have those grounds to change to Lexapro. If the drug company can't come up with reasonable evidence, with every incentive to do so, I can feel fairly sure there's not much to find.
Having said that for a particular patient with a particular problem, where all other logical options have been tried, I would give the rather far-fetched claims for Lexapro a go, but I would prefer to make decisions based on strong evidence before satisfying curiosity about a new drug for which convincing support cannot be found.
I don't think it is unreasonable to look to scientific evidence to inform my prescribing habits rather than just 'having a go' with something new in case it works. If we all did that prescribing would be even more chaotic than it already is. I think large-scale well designed studies actually do carry more weight than one doctor's anecdotal evidence.
I haven't been able to find the data which indicate a lower incidence of sexual side-effects on Lexapro than Celexa - If pharmrep or anyone can point me in the right direction I would be very interested.
Posted by katekite on August 21, 2002, at 11:01:54
In reply to where you been? » katekite, posted by pharmrep on August 20, 2002, at 23:01:33
Dr. Dave seems to have all his ducks in a row. I appreciate that he's taking the time to put forth some straight info that counter-acts what is in my opinion (just my opinion, no personal disrespect intended) misleading information about Lexapro.
Thanks for missing me and enquiring after my whereabouts, Pharmrep. -- kate
PS: keep it coming Dr. Dave!
Posted by Anyuser on August 21, 2002, at 11:02:21
In reply to Re: Knowledge, posted by dr. dave on August 21, 2002, at 8:58:35
1. For all the reasons that are dwelled upon on this board, FDA prescribing info should be viewed skeptically: the FDA is inept, the drug companies are corrupt, lawyers write the thing for lawyers, drug therapy in general is all placebo effect, the science is crap, the studies are too small and too short, etc, etc, etc. The fact remains that in the US there is officially sanctioned prescribing info that states "the overall incidence of adverse effects in 10mg Lexapro treated patients was similar to that of placebo treated patients." On that basis alone, I would not characterize a patient wanting to try that drug or a physician prescribing that drug as "just 'having a go' with something new in case it works."
2. It seems to me that skepticism about the science behind drug approvals can cut both ways. My pdoc, for what it's worth, says that in his clinical experience Serzone is far more effective than the published data indicates. My pdoc happens to be nuts ("barking mad" in the UK?). My point here is not that doctors and patients should hope for benefits not suggested by the scientific data. I do think, however, that clinical experience is a body of knowledge more important than the research data. For example, only 715 patients were tested in the Lexapro research. A busy pdoc would over the course of time have more experience, in absolute terms, with a greater number of patients than the researchers that got the drug approved. For another example, there are meta-surveys out there that "prove" scientfically that all ADs provide only placebo effect, yet you've got patients and practicing physicians that say they don't care what the meta-surveys say, ADs work, however imperfectly.
3. For me, and for most people I know, and for most doctors I know, doctor/patient relationships are evolving beyond what you imply about your practice.
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