Confusion about NDT levo equivalent

I don't necessarily want to annoy the admin staff on here but I can't help but think there's an issue here with advice on NDT dosing. Most of the admin staff are saying 1 grain is equivalent to 100mcg of levo yet all my research has stated its 38mcg. Yes T3 is more potent than T4 but that's it, full stop. It doesn't make T4 more potent it just means it's more effective surely. This is why STTP suggests you start on one grain not a quarter or a half and you don't need to go levo free beforehand just switch. I'm reading post after post of people who are told to go slow who are suffering hypo kick back unnecessarily. If you look at Dr Lowes website he says that the fear of T3 is unfounded nay propoganda. I realise this will make me unpopular but hey isn't it just debate and worth considering. I went slowly and had anxiety and palls so I quickly increased and calm ensued. Discuss.......

58 Replies

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  • STTP should be STTM obviously 😄

  • I have always found this debatable myself.I have a supply of 1grain armour in my cupboard stating that it contains 38mcgs T4levo and 9 mcgs T3.

    The patient leaflet states that the T3 is 4 times more potent.

    By my reckoning that is a total equivalent of 74 mcgs. Levo which is far short of 100.If this theory was right then the more grains you take the more your calculations could be adrift!

  • Yes Marfit, that's my thnking too. But understandably, the manufacturers of desiccated do not want you to overdose so they quote a more conservative estimate as a guide. :)

  • So that would mean that the people (of which there are many) that are on 6 grains would be on 600mcg equivalent! Clearly not and actually the tables on medical sites including the ones cited via this site state clearly 38 not 100

  • Jody,

    38mcg T4 + 9 mcg T3 is equivalent to 74mcg T4 using 4:1 ratio manuf. use. They are not saying 38+9 adds up to 100mcg. They are saying the bioactive equivalent of 38mcg T4 + 9mcg is the same as 100mcg T4 would deliver.

    6 grains would deliver the same impact as 600mcg of T4. I don't know why you say, clearly not, there are a few members on 6-8 grains, several on >500mcg T4 and one posted recently she was taking 1,000mcg T4, certainly the highest dose I've seen reported on the forum.

  • I'm sorry but it's just not stacking up for me. There is no grey area for me. And it would seem not for a) the manufacturers and b) the Endo that prescribed. Surely in an NHS money saving world we live in he would have prescribed a cheaper half a grain if that were truly the case and there wouldnt be post after post of under medicated members? That coupled with STTP recommendation of starting at 1 grain at least? Just a thought. I know you gave to work within constraints

  • Jody, I don't agree with STTM's advice on starting on 1 grain. 9mcg T3 may be too much for someone not used to T3 and 1 grain is too much for someone on less than 75mcg T4.

    The 38mcg T4 and 9mcg T3 in one grain is the content of the active hormones, thyroxine and T3 in each 1 x grain tablet. It isn't supposed to add up to 100mcg or anything else. The action, effect or delivery of that 1 grain tablet is estimated by the manufacturers to be equivalent to the same action, effect or delivery one would get from 100mcg Levothyroxine.

    Why do you think your endo should have prescribed half grain tablets? Weren't you on 75mcg Levothyroxine? Half a grain wouldn't be enough. The manufacturers' conversion would be 3/4 of a grain. I doubt that would have been enough and 1 grain would have been appropriate. I think 2 grains was reckless.

  • Jody, the only constraint an admin has is not to use offensive and sweary words or get into dust ups on the forum. :)

    Whether to post/give advice or not is up to us and any advice we do give isn't endorsed by TUK, doesn't imply medical training/expertise and carries no more weight than any other forum member's.

    I spent 7 horrible months very overmedicated by my oncologist. It was very unpleasant, much more so than being very hypo off meds. Avoiding causing harm by giving injudicious advice is my own constraint.

  • Marfit, the manufacturers are quoting the estimated bioactive equivalence. Probably too conservatively, especially as I think the T3 is only 3 x more potent than T4. See my reply to Jody for link.

  • Comparison table showing the variations in equivalent

    tablet size and / or active ingredients of each of the brands

    Brand of (Natural)

    Desiccated Thyroid USP

    Dose

    Levothyroxine (T4) content

    Liothyronine (T3) content

    NP Thyroid

    (Acella Pharmaceuticals)

    npthyroid.com

    1 grain = 60mg

    38 mcg

    9 mcg

    Armour Thyroid

    (Forest Pharmaceuticals)

    armourthyroid.com

    1 grain = 60mg

    38 mcg

    9 mcg

    Thyroid

    (Erfa Canada Inc)

    thyroid.eci2012.net/

    1 grain = 60mg

    35 mcg

    8 mcg

    Nature-Throid

    (RLC Labs, Inc)

    nature-throid.com

    1 grain = 65mg

    38 mcg

    9 mcg

    Westhroid-P

    (RLC Labs, Inc)

    westhroidp.com

    1 grain = 65mg

    38 mcg

    9 mcg

    HealthXchange

    healthxchange.com

    1 grain = 60mg

    38 mcg

    9 mcg

  • Comparison table showing the variations in equivalent

    tablet size and / or active ingredients of each of the brands

    Brand of (Natural)

    Desiccated Thyroid USP

    Dose

    Levothyroxine (T4) content

    Liothyronine (T3) content

    NP Thyroid

    (Acella Pharmaceuticals)

    npthyroid.com

    1 grain = 60mg

    38 mcg

    9 mcg

    Armour Thyroid

    (Forest Pharmaceuticals)

    armourthyroid.com

    1 grain = 60mg

    38 mcg

    9 mcg

    Thyroid

    (Erfa Canada Inc)

    thyroid.eci2012.net/

    1 grain = 60mg

    35 mcg

    8 mcg

    Nature-Throid

    (RLC Labs, Inc)

    nature-throid.com

    1 grain = 65mg

    38 mcg

    9 mcg

    Westhroid-P

    (RLC Labs, Inc)

    westhroidp.com

    1 grain = 65mg

    38 mcg

    9 mcg

    HealthXchange

    healthxchange.com

    1 grain = 60mg

    38 mcg

    9 mcg

  • This is from thyroiduk.org site

  • It looks as if you are quoting this to suggest that it says "1 grain of Armour is equivalent to 60 levothyroxine" - and even if that is not what you think, someone coming along later could mis-read that.

    It actually means, that Armour use 60 milligrams as their conversion from grains to milligrams of desiccated thyroid.

  • Thank you for sharing very informative.

  • Jody, the 1 grain = 100mcg levothyroxine is the standard conversion rate quoted by the manufacturers of desiccated thyroid preparations. As example, check out the Nature-Throid conversion table on their website here

    getrealthyroid.com/the-real...

    A summary of the levothyroxine and liothyronine content given by each desiccated thyroid brand can be found on the Thyroid UK website here (scroll about half way down the page for the table)

    thyroiduk.org.uk/tuk/treatm...

    I think 1grain = 100mcg T4 is a conservative conversion estimate, but that is not a bad thing in my opinion.

  • I was persuaded to start slowly, so reduced from 150mcg Levo to one grain NDT. Yes, I had hypo kickback and am only starting to feel better now I have reached 2 grains.

  • A reasonable estimate for changing from 150 micrograms of levothyroxine would be to one and a half grains of desiccated thyroid. But that only be to be extra sure that you didn't have a problem, and raising to two grains quite quickly. (We must always remember that any such estimate is to some extent a guess.)

    We do have some members who, for reasons I have never fathomed, insist you should stop levothyroxine for two weeks before switching over. I absolutely disagree with that.

  • I was on 75 levo and Endo prescribed 2 grains. I'm glad he did as I've ripped through and felt no uplift so far and I'm up to 1 3/4 day 9 so the taking it slow and conversion theory doesn't stack up

  • That's right 38 x 2 the T3 is as well as not included

  • My Endo was happy for me to just go for the 2 grains the next day. When I posted this I was told I would be "severely over medicated" so i panicked and took advice on here and went on a quarter. My god that was a big mistake. Really ill with palps and fatigue blah blab. 10 days in and I'm on 1.3:4. Tomorrow I'm going to 2 as I've gone back to falling asleep at 8 sat upright !!

  • Jody, The advice in the thread was to start on 1/2 grain and increase to 1 grain within a week or two.

    healthunlocked.com/thyroidu...

  • I'm exactly the same!

  • Like I say, just wanted to challenge the norm and spark some debate. Dropping from 75mcg of levo to 1/4 grain of armour was pure torture

  • Jodypody, Admins are quoting from the manufacturers conversion guide getrealthyroid.com/the-real... which estimates the bioactive impact of 1 grain containing 38mcg T4 + 9mcg T3 to be equivalent to 100mcg T4. I think the manufacturers overestimate the bioactive impact and the T3:T4 4:1 ratio they use. I believe the T3:T4 ratio to be 3:1 ncbi.nlm.nih.gov/pubmed/204...

    My observation of member responses is that the bioactive impact of 1 grain is probably closer to 75mcg T4 which is why I estimate the bioactive equivalence to members as between 75-100mcg.

    Members on T4 only are advised that there is no need to clear T4 before starting NDT. They are advised to start low and slow when they haven't had T3 before in case they don't tolerate the T3 well. Members on more than the T4 equivalence to half a grain may be advised to taper down their T4 as they introduce and increase NDT to avoid hypo kickback. Anyone switching from T4+T3 or T3 only can start on the equivalent dose of NDT. Bottom line is that cautious and conservative dosing advice has to be preferable to advising members to hop straight onto an equivalent dose of NDT only to find they have a bad reaction to the T3.

  • But surely that would depend on their individual need for T3 replacement ?

  • Jody, yes that's the point. How can anyone know what the individual's T3 need is or how they will tolerate it when they're advising dosing equivalences?. They can only guide dosing when switching to a new medication based on existing medication and, if available, blood results. Needing T3 doesn't mean a member will tolerate the T3 in NDT or the proportion of T4:T3 in NDT is right for that person.

  • Quite a few members have been confused with the 65mg or 60mg of NDT and assumed it was the equivalent to 60/65mcg levo. It isn't as it is the 'effect' of it which is as stated clearly on the link above from realthyroid. Some have taken more than they may have initially taken. So that's why it is stated the 'effect'..... i.e. 25mcg T3 is equal 'in effect' to 100mcg levo. 65mg of NDT is 'in effect' approx 100mcg levo.

    As a form of thyroid hormone replacement, NDT has been in use since 1892 when there were no blood tests and no-one would have had any idea of the consistency of thyroid hormones. It was that it could make a patient better. Neither would the patient care as long as they were given something that made them feel well. Patients died before 1892.

    So, they were diagnosed on clinical symptoms and medical/family history only and give a trial of NDT. If they began to feel better the dose was gradually increased until they felt well. If they felt over-stimulated, the dose was reduced.

    The most important thing is how the patient feels. Not the dose. We are all different, some need less, some need more. It is completely individual. NDT contains, obviously, more hormones than synthetic levo.

    The most important question for the patient from a prescriber is 'how are you feeling' - if we feel well we are on the correct dose. If still having clinical symptoms we either need an increase or a switch to another thyroid hormone.

    For all thyroid hormones, whether synthetic, or natural is how we are feeling. It is not a drug. It runs our metabolism from head to toe. This is an excerpt which I believe is the 'perfect' way to treat patients, not adjusting the dose due to the whereabouts of the TSH which many have suffered from the consequences.

    The mistake many are making is that they are assuming 65mg as equivalent to 65mcg levo and take too much and cannot make sense of the conversions.There have been a few members who have been confused by this 60mg or 65mg when it is the 'effect' which should be considered. This is the perfect way to treat us:-

    Dr. Lowe: With most patients, I use thyroid function tests (TSH, free T3, and free T4) and thyroid antibodies only for a patient’s initial diagnosis. Afterward, I follow the practice, in principal, of Dr. Broda Barnes—that is, measuring tissue effects of particular dosages of thyroid hormone rather than remeasuring TSH, free T3, and free T4 levels.

    My reason for this different protocol is simple: the TSH, free T3, and free T4 tell us only how the pituitary and thyroid glands are interacting. Of course, the test levels may also tell us something of the influence of thyroid hormone over the hypothalamus in its secretion of TRH, another hormone that influences the pituitary gland's secretion of TSH.

    Tissue measures of thyroid hormone tell us what is most important, that is, how the patient's tissues other than the pituitary and hypothalamus are responding to a particular dosage of thyroid hormone. To accomplish this objective, with long distance patients, I mainly use the basal body temperature, basal pulse rate, speed of the Achilles reflex, and the voltage of the electrocardiogram tracing.

    web.archive.org/web/2010103...

  • If anyone takes the time to read 19 reasons section in STTM that's recommended you'll see she states NOT to follow the conversion tables lest you stay hypo or stay on too lower dose for too long. T3 has a short life so you'll soon know if you run in to trouble whereas, staying hypo for the sake of playing it safe, unless you have a heart condition is for me, another few weeks or days of suffering. Frankly Id rather not. If that makes me unpopular then so be it. I've been through the levo to NDT transition and I wish I'd listen ed to my Endo who said switch overnight to two grains. One dose, in the morning equivalent to 75mcg bish bosh

  • I am not going to get into an argument about the whys/wherefores of T3 or NDT. Every one can please themselves. But please do not quote things which aren't quite as they seem.

    I am afraid that what you state about T3 is not quite true.

    You are obviously aware that T3 goes into our bloodstream quickly - is absorbed within a few hours - but your are obviously unaware that it's job then begins as it has to enter and saturate each of the billions of Receptor Cells in our bodies, then it starts to do it's job by sending out 'waves' which last between 1 and 3 days, so therefore, it doesn't have such a 'short life'.

    My last words on the subject: which is an extract re T3:-

    December 24, 1997

    Question: Dr. Smith recently referred one of his patients back to his primary care physician for a prescription for T3. The physician adamantly refused, saying that T3 was old hat, unstable, and caused strokes. Is there anything in the literature about any relationship between T3 and strokes?

    Dr. Lowe: The physician should call a pharmacy and request the leaflet given to patients when they pick up a Cytomel (T3) prescription. The physician would learn, as the patient leaflet on Cytomel explains, "POSSIBLE SIDE EFFECTS: NO COMMON SIDE EFFECTS HAVE BEEN REPORTED with proper use of this medication." Other than Nystatin, he probably will find that no other drug he might prescribe is as free from adverse effects as T3.

  • I totally understand the 1-3 day rule. I'd like to point out again, that my intention was for a debate not an argument and reading the other responses I think that's quite clear. I would be mortified to think I'm trying to undermine anyone especially admin

  • I had to quickly increase from 1 grain to 1 & 1/2 within days.. Sheer exhaustion & couldn't get upstairs.. That was 4 weeks ago, I'm now taking 2 grains & feeling much better... Sttm advised to increase straight away that day & it helped!

  • Thank you. Exactly my point. If you need it you won't get nasty responses.

  • It was actually day 3 that i actually crawled on my knees like a dog at 3.30 in the afternoon... Sttm advised 1/2 increase straight away..

  • So unnecessary though.

  • Jodypody,

    May I point out that the admins are absolutely not staff. Nor are we experts in any sense.

    We might have been round the block a few times, but the reality is that thyroid is so complicated no-one knows it all. There are many non-admins who know at least as much as any of the admins. Our role as admins is to try to keep things in order and help out when needed. However, we also have the same desire to help as so many others here - but that side is really no different to other members.

  • Which is why I was at pains to point out I wasn't having a go and merely sparking a debate which might help others. You have all been a great source of comfort and support I was trying to arm you with more info

  • Jodypody, don't forget that we are all different. The STTM approach works for some people, but not for others. Years ago when I first started on desiccated thyroid, I listened to the advice of those that insisted that we should be taking between 2-3 grains. I was told to start on 1 grain and quickly increase up to two grains. On two grains I felt absolutely dreadful and it took a while to realise that it was not because I was still under-dosed (which is what was being suggested to me), but because 2 grains was actually too much for me. My experience taught me that for some of us, there is a fine line between being under and being over dosed, and it's all too easy to overshoot the mark. Which is why starting cautiously is not as ridiculous as you may think.

  • Hi i'm reading an old post from 2 years ago and you mention you raised ndt too quickly and felt terrible. Out of interest did you get headaches, feel sick and dizzy? I'm trying to work out if i've raised too much or not enough. I was on 125 levo and after 12 days i'm on 1 and 1/4 grains.

  • Complicated? My endo said it was simple! Arrogant young chap.

  • Hi... I just switched pharmacy after being informed the common conversion chart is wrong, before I was told 1grain= 100mcg. Recently I found a new endo and new pharmacy who explained you DO NOT include the T3 content contained in NDT as part of your prescription (T4 recommendations) it is AS WELL AS! For so many of you I bet this makes so much sense now.

    This means for my prescription ( NHS Endo) of 112.5mcg of T4 I actually take 3 grains per day (114mcg T4) but I also have the addition of 27mcg of T3 to compensate for the short fall in t4/t3 due to poor conversion. The T4 is still present to convert where possible but it is extra T3 that helps resolve symptoms in poor converters, and lets be honest if your on this thread you still have symptoms so probably not converting t4 to t3 so well. I am on 3 grains plus 10mcg of Synthetic T3 and doing great, yet my endo insists I still take T4 with the T3 to help my body regulate naturally. Personally I think it is to keep my TSH and T4 in healthy ranges but it's working for everyone.

    I really hope my post helps someone xx

  • The advice given here is necessarily conservative, because we aren't health professionals and we're not in the business of offering medical advice - just experience. I for one wouldn't want to recommend that anyone starts on 2 grains. For every person here who does really well taking two plus grains from the beginning, we probably also have another who runs into trouble very quickly if they attempt to raise their dose too fast. Some people are extraordinarily sensitive to T3. Often it's because they are ferritin deficient or have been left on insufficient amounts of Levothyroxine for so long they've developed adrenal fatigue.

    It's great that you're feeling so much better and that you've been able to raise your dose quickly. But that doesn't necessarily mean that we should recommend that others follow suit. We've had many posts here from people who've raised too soon and are feeling utterly dreadful and don't know what to do to fix the mess they've got themselves into. If you start slow, you give yourself space to detect the often subtle signs that an increased dose is helping or hindering.

  • Yes I'd read beforehand about adrenal fatigue. I've actually had it before so knew what the signs were. Pretty yuck. I do have relatively low ferritin at 26 but my T3 at 3.2 was definitely what was required. So my point is twofold a) the table of conversion is incorrect as pointed out by another member b) If your T3 is low then you're more likely to tolerate as your body is craving it

  • Hi I was on 75mcg of levo and given a private prescription for 20mcg T3. When I found out the cost I told my endo I would like a prescription for natural thyroid instead.

    On the prescription it was to start on 1 1/2 grains and increase to 2 grains after 2 weeks.

    I thought that would be too much as I have never taken t3 before.

    I have decide to try the T3 first after all and even though I initially dropped my 75mcg of levo to 50mcg after a few days I have had to increase back up to 75 as I was falling asleep every day.

    I value the advice on this site as I don't want to bother my private endo all the time and my GP is no help.

    Hope all goes well with your increase x

  • Are you not bothering with NDT then or putting it on hold?

  • My endo wanted me to try T3 first so she could try and push my GP to prescribe it for me on the NHS, but I can't see that happening.

    When I go back to see her in 6weeks I am going to tell her I want to try NDT and discuss why she wants to start me on such a high dose of 1 1/2 to begin with.

  • An interesting topic but not one I've been faced with personally but it has made me think what would I do if I was. Most of us offer advice from personal experience and reading any post where this comes into being so show that we are all different and react differently to change. Many doctors seem to think that once we pop a magic pill we shall be fine and we know that isn't the case. So to me it seems logical on any type of medication change to start slowly. Ok we may have a time of actually feeling no better or even a little worse but isn't that better to slowly introduce a new drug to get our body used to it and then slowly step it up to reach a level we are happy with? I get the impression at times from people newly diagnosed that they are wanting to speed things up but it doesn't work well like that though I can understand why they want to do it. Not of us want to stay feeling rubbish longer than necessary but by slowly nibbling away you know you are going in the right direction. If you go too quickly you stand to have more symptoms than can be both hypo or hyper and it's often difficult to know which way to jump. I'd rather go slowly having more confidence that I'm heading in the right direction.

  • I did start slowly against the advice of my Endo. They wanted me to dive in the next day on the 2 grain dose but I took the advice on here that that was crazy and I would be severely over

    Medicated. This is because they claimed the T3 adage rendered the T4 4 times more powerful so 1 grain equalled 100mcg levo. It doesn't its 38mcg and 9mcg of T3. Yes T3 is more potent but if you need it its welcome! Therefore I would imagine that taking it slow is more for someone who maybe has T3 in or above range??

  • According to Dr Saleeby,MD in STTM2 ,too much T3 in NDT dose can lead to medical problems .Seems safer to go slow and have tests.Have ordered NDT from Thailand to try .

  • Too much of anything ain't good for you baby. Sorry I just burst in to sing 😃. The nature throid from Thailand is supposed to be really good.

  • Well......what a subject this was for debate!!!!!

    I have just finished reading through all comments.

    Last night I decided to get out my patient leaflets for both Armour Thyroid and Mercury Pharma T3 Liothyronine,which are both very lengthy in their content.

    I know that many people can't be bothered with reading them,but when we are dealing with a subject such has aroused so much debate as this I think my reaction this morning was that I would advise anyone using either medication to sit down and read thoroughly.

    As usual there are mentions warning you of any other problems you might have ....including one which I have raised myself recently.... Increased Blood Pressure and T3

    I think at the moment something I have always thought important is the need to be graphic,otherwise people can take from it what they want to hear.I don't think there is any place here for loose interpretation ..... variation between manufacturers,thyroid publications and this or that table.

    I think we have to bear in mind that there are many here who are going it alone self medicating....sending abroad goodness knows where sometimes out of desperation in order to get help,possibly cheaply or purely to get access to something they can't get here in UK because it isn't licensed and yes we are all different in our understanding and reasoning of things.

    I for one sincerely hope that if there is a future debate for the research and licensing of thyroid medication that we get things right so that patients,Gps,Endos and anyone concerned knows exactly what they're doing.

    Meanwhile I assure you I do thank admin for all the work you do in order to try to help us.x

  • Touché.

  • Thank you Jody.....I was worried afterwards that I might have been seen as getting on my High Horse and I'm normally a person who jogs along quietly in life until I get really stirred up then I have a need to say something.

    I do feel passionately for all Thyroid sufferers who are searching for help.

  • ndt made my Hashimotos flare up terribly, having hyper symptoms at a very low dose and STTM, said to ignore this and keep raising, that i had to raise high enough to stop the attack..it almost sent me to the Hospital. I tried ndt 3 times, because STTM says that basically, it is the only way to get well. 3x i made myself ill. T3 only did not have this effect on me, nor did t4/t3 Synthetic, actually. I don't read STTM anymore.

  • I have to admit...I stuffed all my thyroid books away in the bookcase a while ago and decided to just listen to my body. Then my blood pressure started rising so out came STTM.The references to Blood Pressure were so minimal that they were of no help and the book went back on the shelf.

    Am I being unreasonable ? I seem to be developing a dislike for anything priced with a dollar sign and videos that make you sit through 30 mts. or more before they finally try to sell you their product.I would love to find out exactly what five foods I shouldn't eat without having to sit through a load of case histories first.

    All I ever seem to see are pictures of bananas and yet when my husband was in hospital having had aortic heart valve replacement I was asked to take them in to him to help build up his potassium........We both still eat them !!

    Sorry....I'm sounding cynical .....time to do some work.

  • I'd highly recommend the low carb high fat diet. We struggle to break down carbs so that's where stomach issues creep in. I'm on it and my stomach has never been quieter and no more constipation either! Oh and despite being undermedicated I lost 4lbs! (I don't actually need to lose weight as such)

  • Me Too!!! I now distrust anybody that has $ to be made off of my suffering and desperation and we should be leery!!! They do pray on people just like us. I can't sit through any presentations anymore. I have been at this hard, since 2011 and i am totally warn out. I have had food testing done, so i know what to avoid. I have poisioned myself with Coconut and Coffee, both a mild sensitivity and now stopping those. I hope someday to do better than this. Low t3 will cause high blood pressure too. Have you had your frees tested? I am taking t3 only at this point, as t4 made me feel worse and didn't help as much as i hoped. I don't quite know what i am doing, but the doctors know less than i do and treat me so poorly.

  • Sorry for late reply ...have just managed to get back into my I pad after a lock out,however I know how you feel.....nothing seems to go along smoothly for long does it.

    My Endo said last month that my bloods are now good though they are only just inside the lower margins for T4&T3.also in my 70s I'm not keen to be over medicated but you may have a point about my blood pressure.I've reverted to T4 only at the moment but I do have a plentiful supply of T3 which I could try a larger dose with.

  • That's unfortunate to have to go through that. It's so complex trying to find out what eventually works let alone coming to terms with a condition for life

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