How To Treat Erectile Dysfunction Without The Little Blue Pill

Dr. Mark Hyman and Dr. George Papanicolaou Discuss Erectile Dysfunction on The Doctor’s Pharmacy Podcast.

“See, all that the blue pill does is fix that end problem. It fixes that. Let’s just make sure we get the erection and maintain it. But there are reasons why we get there. Hi everyone, I just wanted to let you know that this episode contains some colorful language. So, if you’re listening with kids, you might want to save this episode for later. Welcome to the Doctor’s Pharmacy.I’m Dr. Mark Hyman, and that’s pharmacy with an ‘F’, ‘far macy’, a place for conversations that matter. And if you’re a guy listening to this, or you’re a woman who has a guy, you better listen up because this is about a very common problem. It’s known as ED, otherwise known as erectile dysfunction, which is a very, very common problem. We’re going to get into that, and today our guest is none other than Dr. George Papanicolaou, who’s one of our key physicians here at the Ultra Wellness Center, who is an extraordinary physician, doing great work here, and we are just so excited to talk about this topic. Aren’t we, George?

Discovering the Roots of Male Erectile Dysfunction with Dr. George Shapiro

Thrilled? Absolutely. It’s a little uncomfortable, but I guess we’re going to have to get into it because we’re doctors and we’re professionals, so we can really talk about it. So, George, this is a big problem. Guys are having trouble. Women also have a lot of sexual dysfunction. We’re going to maybe cover that on another podcast. Today, I want to talk about male erectile dysfunction with you because it’s such a big issue. The lucky accident of a failed drug experiment for a blood pressure drug led to the development of Viagra, which I talked about on a podcast with Dr. Louis Ignarro, who is the discoverer of nitric oxide, which is a little molecule that causes your blood vessels to dilate, and that’s how Viagra works.””It was meant to be a blood pressure pill, but it didn’t work so well. However, it worked better for the side effects that the guys got, and all of a sudden, it was a blockbuster pill. Like a blockbuster, which means that people needed it.

Viagra’s Impact on Erectile Dysfunction and the Importance of Open Communication About Sexual Health

So, tell us about the history of this whole story, the prevalence, how common it is, and what is going on. Why are we seeing such an epidemic of this? One of the key things was in 1998 when Viagra hit the scene. It really opened the door for men to have an opportunity to talk about what had been going on for centuries, and that was erectile dysfunction. So, great, Viagra was awesome. Not only did it work, but it opened the door for that conversation because 10% of men under the age of 40 have erectile dysfunction, and by the time you’re 70, you have a 60% chance of having erectile dysfunction. So, that’s a lot of people having erectile dysfunction, and people’s sex lives are not over at age 50, 60, or 70. There are men that come to me wanting to have prescriptions for Viagra at age 70, and I always tell them I’m not giving it to you unless you get a written note from your wife. That’s not going to go well!

Traditional Approaches to Treating Erectile Dysfunction: From Vacuum Pumps to Revascularization

Actually, yesterday I was doing a console with a patient who was 87 years old, who’s still having sex with his wife.I don’t plan on stopping; I’m going at least to 100. Why stop? That’s exactly right. So, this is a very common problem. From a traditional medicine point of view, there really wasn’t much of an approach to this beforehand. We had some really coarse and crude treatments.”Talk about the traditional approach to treating erectile dysfunction, aside from the category of drugs that includes Viagra, Cialis, and Levitra, which are now widely prescribed and effective. Prior to these drugs, there were primitive methods such as vacuum pumps and revascularization, as vascular issues and endothelial dysfunction are key factors in causing erectile dysfunction. Essentially, this means that hardening of the arteries in the penis reduces blood flow and affects the endothelial cells, which are the cells lining the blood vessels in the penis.

How Nitric Oxide Helps Men with Erectile Dysfunction

These cells regulate blood flow and inflammation, and nitric oxide is a key regulator of this process. There are multiple reasons why men experience decreased blood flow in the penis leading to erectile dysfunction. To understand why drugs like Viagra work, it’s important to know that they stimulate the release of nitric oxide, which acts on the endothelial cells in the blood vessels of the penis. It also acts on the corpus cavernosa muscles, resulting in the simultaneous relaxation of those muscles. This allows blood to flow into the big muscles of the penis, which start and maintain the erection. Nitrous oxide also acts on the small blood vessels, causing them to constrict and keep the blood in the cavernous muscles, which further sustains the erection. This process is called tumescence. After ejaculation, the penis relaxes, and this is called detumescence.

Understanding the Role of Metabolic Syndrome in Erectile Dysfunction

Five phosphodiesterase breaks down the compound responsible for the relaxation and constriction, causing the small blood vessels to relax and the penis to become flaccid. Viagra inhibits five phosphodiesterase, allowing cyclic GMP to maintain the constriction of the small blood vessels, resulting in a longer-lasting erection. Metabolic syndrome can affect this process. It is important to remember these chemical names during sex, but it may not be practical.”When you’re thinking about people with ED, all that the blue pill does is fix the end problem – it fixes the erection and helps maintain it. However, there are reasons why we get there. We get there because of stress and its impact on the very sensitive neurovascular system. This system needs to function properly for you to have an erection and ejaculation. Metabolic syndrome, which is pre-diabetes, includes obesity, dyslipidemia (abnormal cholesterol and triglycerides), hypertension, and insulin resistance.

Insulin Resistance and Endothelial Dysfunction: The Root Cause of Erectile Dysfunction

Insulin resistance is connected to endothelial dysfunction. When the endothelial cells aren’t working, nitrous oxide won’t have an impact, and you won’t be able to start an erection. While you can give the person Viagra, it’s better to fix the underlying metabolic syndrome, which has many other impacts on overall health, health span, and lifespan. Basically, people are eating lots of sugar, starch, and unhealthy food, which leads to pre-diabetes and other health problems. This problem affects every other American, and if you take out the kids, it’s probably more than half of the adults.

Insulin Resistance Linked to Erectile Dysfunction and Cardiovascular Disease, Says Expert

Therefore, we have 75% of people overweight and 88% metabolically unhealthy in this country.”Most of those people have some degree of insulin resistance, and what you’re saying is that when you have this phenomenon going on in your body, it damages the ability of the lining of your arteries to function properly. So you can’t get blood flow in your organs, not just in your penis, but in your heart and brain, which is why insulin resistance causes heart attacks, strokes, and dementia. This is all connected, and in fact, the first sign of heart disease is probably having trouble getting an erection. You should be worried about your heart and brain because they’re the ones that are really the target of what’s going on.I think people don’t realize that it’s not just a local problem; it’s a systemic problem.

Functional Medicine: Addressing Root Causes of Erectile Dysfunction for Overall Health Improvement

That’s one of the points I really hoped to make today because, as important as erections are, it’s getting those root causes that impact your overall health, and then the cherry on top of the pie is greater actions.I think most people don’t realize that our whole system is connected, and that’s what’s so different about functional medicine. It’s looking at the whole system. Most people don’t think of their diet when they think about having sexual dysfunction, but that’s the first thing we think about. We do think about stress, for sure, as that plays a role, but there’s also alcohol. One of the roles that alcohol plays is that when you’re drinking alcohol, that itself is going to impact that endothelial dysfunction during the time of use, and you may not have an erection that night. Here’s what happens: you can stop drinking and say, “Okay, that will fix it,” but something happened. You had this issue.”You can have a psychogenic response called performance anxiety.

Performance Anxiety: The Main Cause of Erectile Dysfunction for Most Men

For some men, once they experience failure, it multiplies and they develop performance anxiety, which becomes a psychogenic problem. The vast majority of men with erectile dysfunction actually have a performance anxiety or psychogenic cause. Basically, if it doesn’t work once, you’ll be afraid it won’t work every time, making the problem worse. It’s a hard mental thing to fix, but the fascinating thing to me is that the phenomena around seeing this as a systemic metabolic vascular issue is so important. There are many ways to address it, which we’ll discuss. There are also new ways to address erectile dysfunction beyond Viagra. Traditional medicine offers the vacuum pump, which is pre-Viagra, and penile implants that can work. Alprostadil is an injection or something that goes inside the urethra and the penis, which is a prostaglandin. Revascularization is another option, which I would love for you to talk about.

Revascularization and Other Treatment Options for Erectile Dysfunction

Revascularization is essentially having hardening of the arteries, and there are two ways to do it, just like you have angioplasty or stents placed in the heart.”The same thing can be done for the penis, and that’s one possibility. It’s basically angioplasty for your penis. Yeah, wow, that’s incredible.I know, yeah, again. These are very interesting responses to the problem, but I would like to go through other possibilities. As you said, we’re going to talk about stem cells and platelet-rich plasma.I always like to go back to the idea that you can be revascularized by why get there in the first place, exactly right? You know it’s like you get a stent, but you got a fixture. All of these things actually work.I mean, I’ve had patients of mine use the vacuum pump.I don’t know how they do it. It works, doc.I love it.I’ve had people get penile implants. It works, doc.I love it, and they’re pressing their testicle, and they’re getting their erection, and you know that’s how the pump works.

Exploring the Link Between Testosterone and Erectile Dysfunction in Aging Men

You know they have the pump inside one testicle, and you start pressing on it, and it gives you your erection, and it works.I’ve had men use the injections. They feel like 18 years old again, but they all have diabetes, hypertension, metabolic syndrome, and I can’t get them to get to that underlying cause. So almost sometimes when I don’t let them get their erections right, well, let’s talk about testosterone because there’s this whole conversation out there about male menopause or andropause, and this whole syndrome of low t or low testosterone, and I think part of it’s gone to the extreme, and there are a lot of bodybuilders using testosterone. And I think it can be used inappropriately, but what I want you to talk about is why do we see the drop in testosterone as men age because I think this is really important.

Natural Ways to Boost Testosterone and Improve Erectile Dysfunction

There are natural ways to raise testosterone. There are ways that we are living that lower testosterone. So let’s talk about fixing testosterone, because when you do, a lot of things improve. Erections may or may not improve, but testosterone definitely impacts erectile dysfunction. It affects the five phosphodiesterases we discussed earlier and can also affect nitric oxide, resulting in better erections. You asked why testosterone levels drop off, and while there is a natural decline as men age, losing about one percent per year after age 30, this alone is not the only reason. Many older men have high testosterone levels, while others do not. Those who do not may have sleep apnea, drink too much alcohol, have diabetes, or struggle to manage stress. Pre-diabetes and insulin resistance are particularly problematic, and the more belly fat a person has, the lower their testosterone. Alcohol is also an issue, as it increases aromatase, an enzyme that converts testosterone to estrogen.

Alcohol and Diet: Key Factors Contributing to Erectile Dysfunction in Men

This is why men who drink heavily may experience lower testosterone levels. Men can develop man boobs, big bellies, lose hair on their chest and legs, and have high estrogen levels, making them more like women. It’s important for men to understand that alcohol consumption and diet can contribute to erectile dysfunction. Eating starch and sugar can lower testosterone levels, but consuming healthy fats can increase testosterone levels by providing the precursor molecule for hormone production. It’s crucial to also prioritize good sleep, stress management, and limit alcohol intake. Dr. Hyman thanks listeners for tuning into the podcast and introducing experts who share valuable insights.I am doing something called Mark’s Picks, which is my weekly newsletter. In it, I share my favorite things from food to supplements, gadgets, and tools that enhance your health. It’s all the cool stuff that my team and I use to optimize our health, and I would love for you to sign up for the weekly newsletter.

Functional Medicine Approach to Addressing Erectile Dysfunction and Low Testosterone: Getting to the Root Cause.

I will only send it to you once a week on Fridays, and I promise not to send anything else. All you need to do is go to drhyman. com/picks to sign up, and I’ll share with you my favorite things that I use to enhance my health and live younger longer. Now, back to this week’s episode. Let’s talk about a functional medicine approach to addressing erectile dysfunction and low testosterone, which often go together. When someone comes in complaining of this, I want to make sure that I make the right diagnosis.I always emphasize the fact that when people come to my office, I’m going to get a timeline of events.I want to know everything that has happened throughout their lifetime, including early eating habits, traumas, stressors, disease patterns, antibiotic and medication use, and trauma. All of these things create a timeline, and once you have that timeline, you can begin to piece together a narrative that leads you to the root cause or causes of their disease.

Erectile Dysfunction: Uncovering Underlying Health Issues Beyond the Obvious Symptoms

It can be easy for a person to come in and tell me they have erectile dysfunction. It started about three months ago when I tried to have an erection, but I couldn’t when I was with my girlfriend. Ever since then, I’ve been having a problem. Oftentimes, it’s not as clear as the patient thinks it is. By asking them for a long history, I start to find out that maybe that wasn’t the key turning point. He was slowly building up because of other issues, such as alcohol use, a family history of dyslipidemia, and high cholesterol and triglycerides, which may lead to early vascular disease. It’s really important to make sure we get to all those issues and not be biased by a patient’s opinion or what they identify. When we’re talking about functional medicine, we’re talking about a detailed timeline and using the matrix, which is a paradigm that looks at systems and not symptoms.

Understanding the Impact of Lifestyle on Body Systems in Erectile Dysfunction Treatment

It takes your conditions and attaches them to your various systems, such as your cardiovascular system, immune system, or GI system. We want to know how all those stories, symptoms, and lifestyles are impacting those systems because they all work together. To get your body to work the way it’s supposed to, you have to deal with all those things, such as inflammation, which can affect endothelial function. Toxins like mercury and lead can also impact endothelial mitochondrial function. It’s not a matter of whether you have heavy metals, but how much you have and how well you’re detoxing.”So, I also want to know about your exposure to toxins. That’s how I start when someone comes in to see me.I also think very similarly to you and go through the matrix, but there are things I’m really focusing on.I’m looking at what their diet is. Are they eating an inflammatory diet?

Insulin Resistance: A Common Underlying Cause of Erectile Dysfunction?

Anything that causes inflammation will damage the blood vessel linings and can affect blood flow, such as processed food and fried foods. Lack of protective foods that are anti-inflammatory is also important. These are things that will really dig into looking at insulin resistance. Does this person have pre-diabetes? We look at insulin levels and things that nobody really looks at traditionally.I think the insulin resistance thing is almost 8 out of 10 of my patients that come here to the Ultra Wellness Center. They don’t just get a blood sugar or hemoglobin A1c. They primarily get a fasting glucose tolerance test. That’s the most sensitive way to uncover insulin resistance because it can be hidden. If we use the current standards of a fasting blood sugar of 100, that’s not low enough. It needs to be lower. When you do a fasting insulin resistance test, a person fasts and after that fast, you give them 75 grams of sugar.

The Importance of Measuring Insulin Levels in Managing Glucose and Testosterone Levels for Erectile Dysfunction Treatment

Then you see how their body responds and how they produce insulin in response to that bolus of sugar. If they’re able to keep that blood sugar at a normal range at lower levels of insulin, we know that they have a very good carbohydrate metabolic glucose and an efficient way of managing glucose. But you’re right.””But if you see someone who is able to manage your sugar and insulin, that’s the key. However, I’ve seen patients who, for example, have normal sugars but high insulin. Here’s the take-home point: when you go to your doctor and ask for a glucose tolerance test, good luck. If you get it, they have to measure insulin, which most doctors don’t do. You can measure fasting insulin, but most doctors don’t even do that. If your insulin is over five, you probably have an issue, and if your triglycerides are higher and HDL is low, it’s a concern. So, I’m looking at all that, and I’m also thinking about what’s going on with their testosterone levels.

Functional Medicine Tests for Adrenal Dysfunction in Erectile Dysfunction Patients

I’ll look at total free testosterone and other markers to get a sense of their adrenal stress and whether they have adrenal dysfunction or are chronically stressed. We can look at things like DHEA or saliva cortisol, but these are not tests that you will get through your primary care physician. At Harvard Vanguard, for example, it’s just not going to happen. However, I do think you’re right. We’re looking under the hood and have very specific tests to do that. Functional medicine is like looking under the hood of a car, while regular medicine is like trying to diagnose what’s wrong with your car by listening to the noises it makes. We don’t guess; we test, and we happen to have really good tests at the ready. The glucose tolerance test is a conventional test.”We can all do it, it’s just a matter of understanding the need for it. Then, as you know, we look at our lipid profiles.

Advanced Testing: A Comprehensive Approach to Erectile Dysfunction Treatment

We don’t use the conventional lipid profile, but instead use the NMR and look at markers of inflammation that may not always be looked at, such as oxidative LDL. LDL can become oxidized due to inflammatory states, so we also look at CRP, which is like rancid fat in your blood and isn’t good for your arteries. We also look at other inflammatory markers, which are critical. We do advanced testing, including a four-point cortisol test, as part of a profile that also looks at hormones such as estrogen, progesterone, and testosterone. This not only tells us what your totals are, but we can also see if you’re an aromatizer. On the tests that I look at, I can see the pathways in your physiology that show me testosterone being converted to estrogen. Are you over-aromatizing and producing too much estrogen? Some men are naturally over-aromatizers, and they may come to me complaining about having a hard time with erections or having belly fat and boobs since childhood.

John’s Case: Addressing Erectile Dysfunction Beyond the Little Blue Pill

After doing this test, I can show them that they are physiologically over-aromatizers due to genetic reasons. There are natural inhibitors of aromatase that can block that conversion, and we can do something about it. There are even medications that can help with this, such as Remodex, which is used to prevent breast cancer by reducing estrogen in the body. There are many tricks available to us, and as we work on these things, we can also help with erectile dysfunction. However, these are not simple issues to address, and it’s not always a matter of just taking a little blue pill. Let’s discuss a patient I had named John, who came to me with erectile dysfunction. John was a classic case, 56 years old and not feeling up to par. Despite being told by his doctor that everything was fine, he knew that his erections weren’t as strong as they used to be, and he wasn’t sleeping well or feeling as energetic.

High-Stress Job and Lifestyle Contributing to Erectile Dysfunction in Middle-Aged Men, Study Finds

He was also at an age where menopause was prevalent. John was a bit overweight and had a high-stress job as an international sales manager, which involved a lot of socializing and drinking. As a result, he had extra belly fat and was drinking too much.”He wants to retire early. He’s very focused on his retirement and making his bonuses so that he can save tons of money, and he’s very proud of that. The officers were talking about his treatment. Of course, he says his main focus is really his erections. He said that Hindi and Kennedy were about to have diabetes over and over again, so it was just a matter of saying, ‘Let’s work on your lifestyle before we condemn you to a lifetime of paying for a little blue pill.’ So, if you want to overall feel better and have erections, let’s start working on it.

Insulin Resistance and Pre-Diabetes: Addressing the Root Cause Through Diet

The first thing I did was get all the testing done, including a fasting glucose tolerance test, and of course, he had insulin levels way above 40 at an hour and two hours, which is significant for insulin resistance. He was actually on the board of being declared totally pre-diabetic. His hemoglobin A1c was 5.6, so 5.8 is considered pre-diabetic, but I told him for all intents and purposes, he’s pre-diabetic. Why do I do that? Because when they hear the word insulin resistance, they don’t know what that is, but when they hear the word diabetes, they know what that is, and that’s bad. So, I purposely say that he’s pre-diabetic. All of a sudden, I have leverage. ‘How do I fix that, doc?’ he asked. ‘Let’s work on your diet,’ I said. The first thing we did was put him on a cardio metabolic diet. We detoxed him by taking out sugars, processed foods, gluten, dairy, alcohol, soy, and basically put him on a whole food, vegetable-based diet.””You know, a clean diet minus those things.

Stress Management and Nutrition: Key Factors in Treating Erectile Dysfunction

Just that alone in the first six weeks definitely leads to me feeling better, losing weight, and sleeping better. The second thing I tend to focus on is stress, particularly in men. So, I tell them that by the time they come back to me in six weeks, I want them to have established a good stress management program.I’ll get even more specific and say that I want them meditating at least once a day.I am a huge believer in the power of meditation to alter every part of your physiology, improve it for life, and actually slow the aging process in many parts of our body, most particularly the brain. So, I really emphasize meditation and stress management. That’s what I did with John. John’s lifestyle change started with nutrition, followed by meditation, and then some additional things like fish oil and vitamin D. His vitamin D was really low, at 17. Vitamin D is a very important precursor to all hormonal function, so we got his vitamin D up.

Natural Approaches to Improve Erectile Function and Testosterone Levels

We also got his fish oils to reduce inflammation as he lost weight.I gave him an adrenal adaptogen to help him modulate his cortisol, because cortisol can impact erectile function. After about nine months, he lost weight and his testosterone was low, in the low 400s. We talked about testosterone replacement, but I really pushed him to focus on diet, stress management, and sleep. We did those things and he felt better. By the time we were done in nine months, his hemoglobin A1C had gone down to 5.1 and his blood sugar was way better. He had dropped 23 pounds.””He was sleeping better, started meditating, and his erections were a lot better. They weren’t perfect, but the doctor said they were tremendously better. That’s such a great story, and I think there are also other things out there that people are using. When do you decide to give someone testosterone? That’s a reasonable thing to do as guys age, right?

Testosterone Therapy: An Effective Treatment for Improving Sexual Function

I think there’s some controversy about it, but it can definitely help increase desire, libido function, pleasure, and orgasm. So, when would you decide to give someone testosterone? In his particular case, his testosterone wasn’t where it should be. It was 450, and, like I said, things weren’t perfect even after nine months. So, we talked about testosterone at that point.I use it when somebody’s done everything they can to really improve their lifestyle, manage their metabolic syndrome, manage their insulin resistance, manage their hypertension, manage their stress, and their testosterone just isn’t budging. That’s when I use it, and so I did.I put John on testosterone, and you can do it topically, with injections, or with pellets. There are a lot of ways to do it that a doctor can prescribe, and you have to monitor it. You also have to make sure you take the right supplements with it to regulate some of the things that happen around estrogen, so it’s going to be a really effective treatment.

Boost Testosterone Naturally with Diet and Exercise to Treat Erectile Dysfunction

What’s interesting is you can increase your testosterone significantly by fixing your diet, adding more fats, decreasing sugar and carbs, reducing stress and alcohol, and exercising. Exercise is a very interesting thing that happens to the body. When you exercise, you can boost testosterone, but there are very specific exercises that can do that.”Can you talk a little bit about that? Specifically, what exercises will improve testosterone levels? Number one is aerobic activity, and number two is high-intensity interval training. Those are the two that I recommend the most for patients, in combination with weight lifting. Why do you recommend weight lifting? Well, weight lifting is beneficial for multiple reasons. Muscle mass helps improve carbohydrate metabolism, and it is also important for aging. You need muscle to be able to move and function properly. That’s why I prescribe exercise, particularly weight lifting.

New Treatments for Erectile Dysfunction: Testosterone, Stem Cell Injections, and Shock Wave Therapy

On the other side of that, I also prescribe testosterone to help men make muscle gains. Often, they’re not making muscle gains while working out, so testosterone can benefit them in dealing with insulin resistance and metabolic syndrome, and help them age more appropriately. Absolutely, I think that’s right. Testosterone can help, but weightlifting and using heavier weights can also build testosterone along with increased fat. There are a few other treatments that are up and coming, such as stem cell injections, exosome injections, and platelet-rich plasma. These are being used to varying degrees of effectiveness. One treatment that I find fascinating is shock wave therapy. This is an ultrasound shock wave therapy that is applied to the penis with a little ultrasound device. They use a little lidocaine to anesthetize the penis because it’s a little uncomfortable, but it usually takes about 15-20 minutes.

Comprehensive Approach at Ultra Wellness Center to Help Men with Erectile Dysfunction

It’s done over a period of weeks, and what it does is help to break down some of the stiffness of the arteries that are causing decreased blood flow. This can really increase blood flow and vascularization, and it’s been well-researched. So, I think that’s another interesting avenue, but I think for men listening and women who are married to men, this is a solvable problem. It’s an embarrassing problem, and there’s a stigma about it. People feel anxious talking about it, but often it’s a medical issue that can be sorted and solved. Sometimes you need to think a little bit out of the box, and it’s just not as simple as taking Viagra or Cialis. There’s a lot more to it, and I think that’s really the approach we take here at the Ultra Wellness Center. It’s a comprehensive approach that looks at all the factors in someone’s life that may be impacting their sex drive, sexual function, and their ability to enjoy life well into their 80s and 90s. So, absolutely, I think it’s important.

87-Year-Old Patient Inspires Strategies for Better Sexual Health, Says Doctor Mark Hyman

I was very inspired yesterday talking to a patient who’s 87 and still having sex with his wife. We were just talking about how to make it a little bit better. But that is possible if you pay attention to the quality of your health and deal with your lifestyle. So, George, thank you so much for being part of the Doctor’s Pharmacy House Call podcast. If you’ve been listening to this and you love the podcast, share it with your friends and family, maybe not your mother, [laughter], but certainly leave a comment. We would love to know how you have managed through this difficult problem, whether you have struggled with it yourself or if your partner has. Subscribe wherever you get your podcast and we will see you next time on The Doctor’s Pharmacy. Thanks, Mark.

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