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1. Thyrogen (thyrotropin alfa) is used to help identify thyroid disease by testing the blood for a hormone called thyroglobulin in the follow up of patients with a certain type of thyroid cancer known as well differentiated thyroid cancer. 52 (72% of range) and my Free T3 283 (only 28% of range.) Medications like NDT (Armour thyroid and WP thyroid) or Cytomel/liothyronine, contain T3 and can be added to your current thyroid regimen. Levothyroxine helps regulate your metabolism and energy, as it is a replacement for a hormone your thyroid normally produces that does this. The phase IV clinical study analyzes which people take Cytomel and have Withdrawal syndrome. Ive discussed various options for patients post-thyroidectomy in this post here. Busnardo, B., F. Bui, and M. E. Girelli. Very few studies measure LT3 withdrawal in both types of patients at the same time on the same laboratory tests. The symptoms that you will experience tend to mimic the symptoms of hypothyroidism (which probably lead you to your Doctor, to begin with) but may even be worse. #1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1980928/, #2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2585732/, #3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4737508/, #4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2784889/, #5. https://www.ncbi.nlm.nih.gov/books/NBK278958/, #6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5682381/. arm, back, or jaw pain. crying. All rights reserved. Lees study in 2010 compared 1) LT4 withdrawal, 2) LT3 withdrawal, and 3) supplementation with recombinant human TSH (rhTSH), to achieve a very good TSH stimulation averaging 82 mU/L. Other drugs that have the same active ingredients (e.g. Rapid heart rate and palpitations. Drug cravings. In addition, its estimated that up to 5% of lab tests are inaccurate (just from the standard error of measurement). Included with diet and exercise should be stress reduction techniques. I started back on it today, but have had cold chills (alleviated by aspirin) for the last 3 days. However, without thyroid replacement medication, a person with overt hypothyroidism cannot function optimally and will suffer from the physical and mental symptoms of hypothyroidism. Dosage of drugs is not considered in the study. Hey! . But you have to ask yourself a very important question: Are their experiences, medical conditions, circumstances, etc. They are most likely (more than probable) from coming off the Zoloft. The normal subjects were placed on T3 doses of 50 mcg daily the 1st wk, 75 mcg daily the 2nd wk; and 100 mcg daily for the last 10 d., The athyreotic patients were switched from oral thyroxine replacement to oral T3 (Cytomel), 75 mcg daily., There was only one dose per day. Giving it one more week. This process is called thyroid hormone withdrawal (THW). Symptoms that impair complex and demanding tasks may appear long before the half life of the dose if one starts from a position of LT3-dependent euthyroidism (Busnardo et al, 1983) and then progresses all the way to depletion of T3 without any T4 support. Ive done research and came to find out that bodybuilders c Im not depressed and my daughter is 11 years old. Compare the rates above to the pharmacokinetics of a 50 mcg single dose of LT3 in healthy euthyroid subjects over the same time period. Excerpted, with permission, from pages 92-93 of "Withdrawal of Thyroid Hormones," Chapter 915of the reference book "Thyroid Cancer: A Guide for Patients", Keystone Press, 2010. This content is strictly the opinion of Dr. Westin Childs and is for educational and information purposes only. Synthroid is FDA pregnancy category A - it is definitely secure for breastfeeding Synthroid or Levothyroxine in its generic form, is a a commonly used medication to treat Hypothyroidism, an underactive thyroid. Genital symptoms (0-3) were also overemphasized compared to fatigue. Perhaps men designed this survey? Lee, Jandee, Mee Jin Yun, Kee Hyun Nam, Woong Youn Chung, Euy-Young Soh, and Cheong Soo Park. I also happen to formulate the best supplements on the market (well, at least in my opinion!) A person can go for many years without thyroid hormones. . The thyroid is like the engine of your body. When Thyrogen is used to help detect thyroid cancer, there is still a chance all or parts of the cancer could be missed. The study uses data from the FDA. Common side effects of Cytomel include nausea, diarrhea, and headache. In a study of people being prepared for treatment with a form of iodine after thyroid surgery, results were similar between those who received Thyrogen and those who stopped taking their thyroid hormone for up to 5 years after treatment. Thyroid patient since 2003. Diabetes & Endocrinology 3 (10): 81625. The problem with stopping your medication (abruptly or otherwise) has to do with how thyroid hormone impacts your body. The quantitative results were as follows: The Quality of Life scores were equally poor for LT4 and LT3 withdrawal, the maximum score for the poorest quality of life being 31. Side Effects. Learn which foods you should avoid if you have thyroid disease of any type. It was especially difficult for the LT3 withdrawal patients to answer with maximums for their 2 weeks of withdrawal alone, since the maximum scores often required an answer of always, or a duration lasting more than 2 weeks, or an event occurring more than 2 times. In the treatment and follow up of thyroid cancer, for certain procedures, you need a high level of thyroid stimulating hormone (TSH). 2019. If you feel like you are stuck with your current thyroid medication and arent sure what to do then this is the section for you. Hydrocortisone is a man-made version of a natural substance ( cortisol) made by the adrenal gland. Learn more. Experts calculate this period using the half-life of a drug. Results of our real-world drug study have been referenced on 600+ medical publications, including The Lancet, Mayo Clinic Proceedings, and Nature. Quality of Life and Effectiveness Comparisons of Thyroxine Withdrawal, Triiodothyronine Withdrawal, and Recombinant Thyroid-Stimulating Hormone Administration for Low-Dose Radioiodine Remnant Ablation of Differentiated Thyroid Carcinoma. Thyroid: Official Journal of the American Thyroid Association 20 (2): 17379. I'm Dr. Westin Childs. In case you arent already aware, another very important factor that is within your control is the food that you put into your body and how much you exercise. Ordering and obtaining all of the thyroid lab tests will help give you information about how well you are absorbing thyroid medication, how well you are utilizing it in your body, how your body is metabolizing/converting it, and so on. Feeling jumpy and restless. abdominal cramps. The use of the eHealthMe site and its content is at your own risk. 48 hours, maximum. Myxedema Coma in a Patient with Subclinical Hypothyroidism. Thyroid: Official Journal of the American Thyroid Association 21 (1): 8789. A high level of TSH facilitates thyroid cancer treatment and detection of remaining, recurring, or metastatic thyroid cancer. Medical resource utilization (0-6) included questions about how many times 1) did you consult your physician, or 2) were you treated in a hospital for relief of your symptoms. Illogically, the only options were Not at all, and one time (1), but no option was offered for two times. The maximum score of 2 was only given to more than two times.. Studies of LT3 withdrawal have usually waited 2 weeks post-withdrawal. Ultimately, legal steroids are a safe and effective way [] 2012. This is a compensatory mechanism by which the body reduces the effect of hypothyroidism on the one hand, and can clear out short term excess on the other hand. 2008. It does sound like the hormones left in your system are still pretty high. Increased weight gain. Low intracellular T3 secondary to hypothyroidism is the basic underlying pathology in myxedema crisis which leads to hypothermia and suppression of cardiac activity. Erlotinib Hydrochloride and Fungal Sepsis, Amlodipine Besylate and Vitamins drug interaction, Headache (pain in head): 8 people, 25.81%, Drug Administration Error: 5 people, 16.13%, Mobility Decreased (ability to move is reduced): 5 people, 16.13%, Drug Exposure During Pregnancy: 4 people, 12.90%, Malaise (a feeling of general discomfort or uneasiness): 4 people, 12.90%, Headache (pain in head): 5 people, 16.13%, Arthritis (form of joint disorder that involves inflammation of one or more joints): 5 people, 16.13%, Fibromyalgia (a long-term condition which causes pain all over the body): 5 people, 16.13%, Neuropathy Peripheral (surface nerve damage): 5 people, 16.13%. I felt the thyroxine withdrawal six days after stopping it. 2009;53/6, 4) K. Burman;Hypothyroidism Symptoms Following Temporary Withdrawal from Thyroid Hormone; Excerpted, with permission, from pages 92-93 of Withdrawal of Thyroid Hormones, Chapter 915 of the reference book Thyroid Cancer: A Guide for Patients, Keystone Press, 2010. If you have questions regarding your health you should seek qualified information from a medical professional or your doctor. In clinical studies, the most common side effects reported were nausea and headache. chest pain or discomfort. nervousness. Ive written extensively about diet, exercise, and thyroid function on this blog before so I wont go deep into it now. Call1-88-THYROGENto speak with a Case Manager. muscle aches, weakness, or cramps. If you have Hashimotos, and youve had it for many years, there is a good chance that you have some element of permanent thyroid damage to your gland. You may be prone to anger spells and have a difficult time controlling your anger. In general, a handful of common physical withdrawal symptoms include: 4. Alpha Lipoic Acid (ALA) and Thyroid Health: Is it Safe to Use? It was cobbled together by doctors who did not want to make it seem like they were harming their patients. Whenever possible, its always a great idea to take your health into your own hands, do your own research, and make informed decisions about your body and health. To obtain a high level of TSH, your doctor may choose to temporarily stop your thyroid hormone medication four to six weeks before treatment with radioactive iodine (RAI), or for diagnostic testing. menstrual changes. In many cases, adding some T3 to your current medication regimen is enough to improve your symptoms dramatically. https://doi.org/10.1186/cc6211. T3 and T4 will require a physicians supervision. Your body then becomes reliant upon the medication that you are putting into your body each and every day. Thyroid hormones are regulated by the FDA which means that they require a prescription medication. 1 years. Patients with kidney disease:Thyrogen exits the body much slower in dialysis patients and can lead to longer high TSH levels. Symptoms associated with stopping thyroid medication include: Worsening of brain fog. Full-time research professor of communication. The survey minimized several debilitating symptoms such as fatigue, insomnia, cold intolerance, and weight gain. Cytomel can be taken with or without food. restlessness. Normal levels of TSH are between 0.4 to 4 mlU/L. Is your current physician unwilling to work with you to try something new? Pregnant patients:Notify your healthcare provider immediately in the event of a pregnancy. Seehttp://www.thyca.org/about/TCGuide/, 5) Jason Baker MD; The Effects of Hypothyroidism in the Body;https://www.healthline.com/health/hypothyroidism/effects-of-hypothyroidism#1; Accessed June, 2020, 6) RADIOACTIVE IODINE FOR THE TREATMENT OF THYROID CANCER. Cytomel and T3 thyroid hormones have a direct effect on the heart and cardiac tissue. The process may take from a couple days to a couple weeks to create Cytomel T3. On Sunday I'll take my last Cytomel, having taken it for 2 weeks. The inability to think clearly. Jun 2022 24. spezzatino al sugo con patate in pentola a pressione Facebook; unexpected wedding readings Twitter; mon voisin fume de l'herbe et ca sent chez moi Google+; thomas wright obituary 2021 . These people didnt fall below 100 ng/dL TT3 because they had T4 in circulation, which did not have time to clear out, and some of which continued to convert to T3 every minute of every day. This T4-only thyroid medication may be one of the reasons that you arent feeling well. When you use supplements make sure that you find very high-quality supplements, and make sure that you are using it for your desired outcome. nausea. Fortunately, there are VERY few deaths from these conditions due to the ability to catch and diagnose thyroid dysfunction. diarrhoea. Check out my thyroid supplements. Weigh pro's and con's of treatment (see Q2). Dehydration is common during withdrawal. TSH is part of an important axis known as the hypothalamic-pituitary-thyroid axis (5). The mean half-life in this study must be interpreted as the half-life of I-125 radioactive iodine tagged T3 in three different situations: Nicoloff and co-authors found that the clearance rate also depended on the amount of TBG (thyroxine binding globulin) in blood. This prevented their TSH from rising higher and their T3 from falling lower by the end of 2 weeks withdrawal. This may sound depressing, but it doesnt have to be. #4. All rights reserved. I went out of the country with out my prescription for cytomel. Like all bodybuilding steroids, Anavar suppresses natural testosterone. The withdrawal symptoms can appear after as few as 6-8 . Mol Imaging Radionucl Ther. First of all, the survey was not co-designed by patients who had a long experience with hypothyroidism or who had already undergone this withdrawal. Another surprisingly effective strategy for improving your thyroid is through the use of targeted supplements. Thyroid Hormone Withdrawal (THW) this is used to produce high levels of TSH in patients by stopping thyroid hormone pills and causing short-term hypothyroidism. The first half of the half life describes a steep crash; the decline past the half-life takes a much longer time. sun dried tomato bread recipe jamie oliver; laura englander levin wedding; how a guarded man tests you; red thread spaces llc east hartford, ct In addition, Cytomel often needs to be taken multiple times a day since it has a short half-life, resulting in fluctuating levels in the body. . It has been a common practice for many decades to treat thyroid cancer patients after a total thyroidectomy with either LT4 or LT3 monotherapy, and then completely withdraw thyroid hormone prior to radioioidine (RAI) ablation of any thyroid remnants left behind after surgery. If you skip or stop your medicine entirely, you can experience a number of short-term and long-term consequences, including: Debilitating weight loss. This likely has to do with thyroid hormone conversion and metabolism in your body. The half-life of Cytomel is about 2.5 days and experts agree that it takes up to 5 half-lives for a drug . So, if you decide to stop taking your medication your body can only produce the amount that it is capable of producing. If THYROGEN is administered with radioiodine, the combination regimen should not be used in pregnant women. A drug's half-life is the time it takes for 50% of that drug to be removed from the body. Symptoms associated with stopping thyroid medication include: These side effects usually mimic the side effects of hypothyroidism, because if you stop taking your medication your body will not be able to produce it naturally for some time. quick to react or overreact emotionally. This can definitely but difficult, but Ive put together some resources to help. Detoxing or withdrawing without support can lead to relapse. Want to know why I'm so passionate about these topics? Indeed, people often go undiagnosed for decades despite suffering from hypothyroid symptoms. The autoimmune component of Hashimotos may lead to the eventual destruction of your entire thyroid gland which means it can no longer produce thyroid hormone by itself. The worst symptom seems to be the head fog - he can't focus or get anything done - so he says. It could be between 72 hours and 10 days, depending on the individuals T3 clearance rate, prior length of time on therapy with T3, whether T4 hormone is present in blood at the time of withdrawal, and whether a persons own thyroid can produce any hormone. Get my free thyroid downloads, resources, and PDFs here. In order for your body to activate this medication, it must convert it into T3 (through thyroid conversion) and not everyone does this at the same rate. People may assume that when they stop taking thyroid medication their bodies will be able to start producing it on their own. (MADRS) = Montgomery and Asberg Rating Scale This represents 1/5 of your total hormone intake in a day When you look at it that way, 5 mcg is not insignificant. Foods to Avoid if you Have Thyroid Problems: Ive found that these 10 foods cause the most problems for thyroid patients. Dont walk on thin ice. This may include weight loss, fever, headache, anxiety, trouble sleeping, arrythmias, and heart failure. Thyrogen-Induced Hyperthyroidism: Risks Associated with Radioiodine Treatment: ADVERSE REACTIONS Hi, I'm sorry you are having these symptoms. If you spend any time researching on the internet you will always find someone who has a positive experience when they stop taking their medication. However, Cytomel T3 don't mimic the effects of weed. Because when the thyroid hormone levels are high, this gives the signal to your body to run at a very high speed. I go to great lengths to help my users better understand their health; however, the content you see here is not a substitute for medical advice. severe headache. The answer to people in this category may be as easy as increasing your medication. 1980. For example, one of the questions was simply Duration of symptoms: For how long did you experience symptoms and the maximum score of 3 was only permitted for more than 2 weeks.. Cytomel causes an increase in the force of contraction and an increase in the heart rate (9). Levothyroxine is used to treat low thyroid hormone levels in your body, called hypothyroidism 2. 2022 Dr. Westin Childs | Thyroid & Health Supplements That Work Built withGeneratePress and powered by Kinsta. After withdrawal, some symptoms do not appear until after the medication has disappeared from circulation, due to the long-term and cumulative nature of thyroid hormone signalling. In some cases, its actually incredibly risky to stop taking your medication, especially if you have had your thyroid removed or destroyed from radioactive iodine ablation. N . Very bad head fog, depression, etc. A half life can be misleading when the clearance rate is skewed, as it is in LT3 dosing. Liothyronine: answering patients' questions. Fair dealing: See Section 29.1, Canada Copyright Act,https://laws-lois.justice.gc.ca/eng/acts/C-42/page-9.html#h-26, Click to access Fair-dealing-comparison-chart.pdf. Levothyroxine (also commonly known by brand names such as Synthroid, Eltroxin or Levoxyl) is typically stopped for at least four and preferably six weeks prior to the radioactive iodine. Just like your mind gets irritated without nicotine at first, the rest of your body can, too. If the patient has no symptoms before treatment (just a low temperature). Cytomel typically takes about one day to reduce by half. We do not provide medical advice. Proteins triggered by T3 remain in the body and have their own life cycle beyond T3s clearance. This means that there are some people (up to 15% of the population based on genetic studies) who simply dont do well on T4-only thyroid medication. rapidly changing moods. Withdrawal syndrome is found among people who take Cytomel, especially for people who are female, 60+ old, have been taking the drug for 2 - 5 years. TPC President, thyroid science analyst. If THYROGEN is administered with radioiodine (RAI), the serious side effects for RAI apply to this combination regimen. Your loved one might need help with practical tasks like preparing meals, going to the bathroom, and getting around. Studies reported by Nicoloff and colleagues in 1972 calculated a half-life of T3 that varied with thyroid status (8). The most severe and deadly cases, according to Dutta et al, are not among those who were previously undiagnosed, but rather among the people who stopped their thyroid therapy. Its far better, instead, to try other therapies (which are proven to be effective) with a knowledgeable physician. You will notice a drastic decrease in your hormonal level when you stop using Cytomel or any other thyroid medication. WARNING: Please DO NOT STOP MEDICATIONS without first consulting a physician since doing so could be hazardous to your health. Titrate the dose of CYTOMEL carefully and monitor . While your body is trying to heal you will be left with an insufficient amount of thyroid hormone and you will most likely feel worse. Problems sleeping, including insomnia and/or fatigue. Its possible, that through incorrect testing of an isolated TSH test, patients can be placed on thyroid medication inappropriately. Cytomel Side Effects by Likelihood and Severity . See our full disclaimer in "Terms of use.". TSH stands for thyroid stimulating hormone because it stimulates the production and release of thyroid hormone from your thyroid gland. Loss of appetite. This is very close to what you are taking. Please consult with your doctor for a list of contraindications for radioiodine. The benefit of LT3 withdrawal in comparison to LT4 was that LT3 cut the post-withdrawal suffering time in half (2 weeks) by speeding up the rise of TSH. Hashimoto's thyroiditis. generic drugs) are not considered. 9 These symptoms can last a few weeks. The Pharmacodynamic Equivalence of Levothyroxine and Liothyronine. You are now leaving Thyrogen.com and going to a website that is not operated by Sanofi Genzyme. When you take thyroid hormone it causes a feedback loop that inhibits the natural production of TSH from your pituitary gland. It is the second most commonly prescribed T3 thyroid medication for the treatment of hypothyroidism as well as other thyroid-related disorders. Anxiety. Levothyroxine Withdrawal. This typically stems from conditions such as hyperthyroidism or thyroid cancer. June 5. cytomel withdrawal symptoms . In answer to Question 1, the following were only permitted a maximum score of 0.5 each, simply by answering yes/no: It is hard to imagine weight gain or dry skin occurring within only 2 weeks of withdrawal. Therefore, the survey was designed so as to make it nearly impossible to come near to the maximum score of 31 for a severely reduced quality of life. It is obvious why the alternative to withdrawal supplementation with recombinant human TSH (rhTSH) often sold under the brand name Thyrogen was given an average Quality of Life reduction score of 4.2 (pretty good!). It may surprise you that your thyroid is responsible for some very important functions inside your body. A high MCR (metabolic clearance rate) means it is cleared faster. Some symptoms are more predictably responsive than others. Published online 2016 Jun 6. doi: 10.4274/mirt.88598;https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5096624; Accessed June, 2020. To put that in context, thereference rangeof total triiodothyronine (T3) is approximately 80-220 ng/dL in adults. However, the recruitment of healthy subjects is standard in most pharmaceutical testing, and a single tablet rarely causes adverse effects in a healthy person.). The week before I was on nothing, prior to that, thyroxine. The management of primary hypothyroidism with Levothyroxine is usually simple, effective and safe, and most patients report improved well-being once they have started treatment. It takes 4-6 weeks of stopping thyroid hormone medication for the TSH to go up to the levels required for successful radioactive iodine (RAI) ablation and/or diagnostic testing. He recently came off the Cytomel and is feeling pretty bad. Im considering taking T3 after my cycle because ive put on a little more fat than intended. Finally, the half life is deceptive because some people may mistake that the Cmax of a single dose achieves the maximal effect, and that complete clearance removes all the effects of the medication. Sweating and/or chills. Im not sure about Korea (where the study was done), but in our culture, it would require serious symptoms as neurological, cardiovascular or pulmonary distress go to a hospital, and such symptoms were not listed, though even ONE visit to a hospital would likely be for a very severe reason. I don't practice medicine anymore and instead specialize in helping people like YOU who have thyroid problems, hormone imbalances, and weight loss resistance. Douglas Van Nostrand, M.D., Gary Bloom, and Leonard . decreased bone mineral density. At peak levels, a properly dosed LT3 patient with healthy adrenals will not experience any thyrotoxic symptoms. If possible, offer to help with these tasks so your loved one can focus on healing. CYTOMEL has a narrow therapeutic index. Resources, a In most cases, its not worth the energy to fight with your Doctor for tests or medications. The initial dose of CYTOMEL varies with age and body weight. The answer is, not without some extreme suffering. Post-acute and protracted withdrawal symptoms from meth can include: 3. In rare cases, temporary hair loss may occur during the first few months of starting Cytomel (especially in children). 2015. All rights reserved. Your TSH can fluctuate on a daily, weekly, and monthly basis and is sensitive to factors such as stress, supplements, sleep, and so on. Please let me know what you think. With medical big data and AI algorithms, eHealthMe is running millions of phase IV trials and makes the results available to the public. Had to cut the dose to once a day, which hasn't helped much. Thyroid Patients Canada is a registered federal not-for-profit organization. The list includes optimal ranges, normal ranges, and the complete list of tests you need to diagnose and manage thyroid disease correctly! Doctors, never, ever, force LT3 monotherapy withdrawal on a patient who may have no thyroid function. 1983. In people with healthy thyroid glands, the rise and fall in Free T3 and Total T3 is parallel over time. https://doi.org/10.1089/thy.2019.0101. And when I say important, thats really an understatement. https://doi.org/10.1089/thy.2009.0187. Use the percentage index to get a quick start on clinical assessment. Follow me on Facebook, TikTok, and Instagram for up-to-date thyroid tips, tricks, videos, and more. The lines for serum are almost straight. Patients should remain hydrated prior to treatment with Thyrogen. The half life is also deceptive because it does not map onto a single symptom or health impact, such as slower heart rate. One should be familiar with their mechanism of action, basic drug properties, adverse reactions and use with injections. During withdrawal from thyroid hormone, to reduce symptoms of hypothyroidism, your doctor may prescribe a short-acting thyroid hormone called Cytomel (T3) for a few weeks. Obviously, symptoms such as a menstrual disturbance would have less chance of appearing within only 2 weeks post LT3-withdrawal, or if the patient was male or a woman in menopause. The symptoms that you will experience tend to mimic the symptoms of hypothyroidism (which probably lead you to your Doctor, to begin with) but may even be worse. I'm Westin Childs D.O. The chances of this happening are slim, but the chances of stopping thyroid medication and feeling better are also slim. https://doi.org/10.1007/BF03349370. Just realize this is something you should be doing. LT3 monotherapy is often taken in several divided doses per day.) China L-Triiodothyronine T3 CAS 200-223-5 Organic Herbal Weight Loss Raw Steroid, Find details about China Raw Steroid Powders from L-Triiodothyronine T3 CAS 200-223-5 Organic Herbal Weight Loss Raw Steroid - Shenzhen Diamond Pharmaceutical Technology Co., Ltd. Diet and exercise by themselves are probably not enough to cure your condition (though they may for some) but they will allow you to feel better, help maintains your weight, and improves thyroid function. Withdrawal of thyroid hormone, but especially of LT3 monotherapy, can be severely harmful to ones quality of life in the short term. Celi, Francesco S., Marina Zemskova, Joyce D. Linderman, Nabeel I. Babar, Monica C. Skarulis, Gyorgy Csako, Robert Wesley, Rene Costello, Scott R. Penzak, and Frank Pucino.

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