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How a Single Bone Receptor Switch Could Reverse Severe Osteoporosis

How a Single Bone Receptor Switch Could Reverse Severe Osteoporosis

A team of researchers at Leipzig University in Germany and Shandong University in China has identified a molecular switch embedded in bone tissue that directly stimulates new skeletal growth while simultaneously shutting down bone resorption. The findings, published in Signal Transduction and Targeted Therapy, demonstrate that activating a specific mechanosensitive receptor—known as GPR133, or ADGRD1—using an experimental small-molecule compound designated AP503 restored degraded skeletal architecture in animal models exhibiting advanced bone loss.

The preclinical results provide empirical proof that pharmacologically targeting a single receptor can decouple the body's bone-building and bone-clearing mechanisms. By forcing osteoblasts to mature and lay down new mineralized matrix while keeping destructive osteoclasts in check, the therapeutic approach managed to reverse severe osteoporosis in mice subjected to hormonal depletion and aging.

                  ┌────────────────────────────────────────────────────────┐
                  │                 GPR133 / ADGRD1 RECEPTOR               │
                  │   (Activated by AP503 / GL64 + Mechanical Strain)      │
                  └───────────────────────────┬────────────────────────────┘
                                              │
                      ┌───────────────────────┴───────────────────────┐
                      ▼                                               ▼
         ┌─────────────────────────┐                     ┌─────────────────────────┐
         │       OSTEOBLASTS       │                     │       OSTEOCLASTS       │
         │   (Bone Formation)      │                     │    (Bone Resorption)    │
         ├─────────────────────────┤                     ├─────────────────────────┤
         │ • Gs/cAMP pathway ↑     │                     │ • cAMP-PKA-NFATC1 axis  │
         │ • β-catenin activated   │                     │ • Direct suppression    │
         │ • Runx2 / Osterix ↑     │                     │ • Balanced RANKL/OPG    │
         │ • Matrix mineralization │                     │ • Arrested bone erosion │
         └────────────┬────────────┘                     └────────────┬────────────┘
                      │                                               │
                      └───────────────────────┬───────────────────────┘
                                              ▼
                                 NET SKELETAL RECONSTRUCTION
                              (Increased BV/TV, Cortical Thickening,
                               Enhanced Peak Bending Strength)

"If this receptor is impaired by genetic changes, mice show signs of loss of bone density at an early age—similar to osteoporosis in humans," said Professor Ines Liebscher, lead investigator of the study from the Rudolf Schönheimer Institute of Biochemistry at Leipzig University's Faculty of Medicine. "Using the substance AP503, which was only recently identified via a computer-assisted screen as a stimulator of GPR133, we were able to significantly increase bone strength in both healthy and osteoporotic mice."

Lead author Dr. Juliane Lehmann, also of the Rudolf Schönheimer Institute, pointed to the dual physiological impact of the receptor, which operates in muscle fibers as well as skeletal tissue. "The newly demonstrated parallel strengthening of bone once again highlights the great potential this receptor holds for medical applications in an aging population," Lehmann said.

The discovery arrives at a moment of mounting clinical urgency. Worldwide, more than 200 million people live with osteoporosis, including approximately 10 million Americans and six million individuals in Germany. Fragility fractures affect one in three women and one in five men over the age of 50. Within twelve months of sustaining an osteoporotic hip fracture, between 20 and 30 percent of patients die from complications, while half of the survivors permanently lose their functional independence. Current therapies slow bone loss or provide short-term bone stimulation under stringent safety warnings, leaving clinicians without a tool capable of driving sustained skeletal regeneration without severe systemic side effects.


Anatomy of the GPR133 Switch

GPR133 belongs to the adhesion class of G protein-coupled receptors (aGPCRs), a structurally unusual family of 33 human receptors characterized by exceptionally large extracellular domains tethered to standard seven-transmembrane domains. Unlike classical hormone receptors that drift freely in membranes waiting for chemical ligands, adhesion GPCRs function as mechanical sensors. They anchor cells to their immediate surroundings and convert physical stress into downstream biochemical signals.

Extracellular Matrix / Neighboring Cell Surface
        │
   [ PTK7 Ligand ] + [ Mechanical Strain / Fluid Shear ]
        │
┌───────▼─────────────────────────────────────────────────────┐
│  EXTRACELLULAR DOMAIN (GPR133)                              │
│  - Adhesion Motifs & Autoproteolysis Inducing (GAIN) Domain │
└─────────────────────────────┬───────────────────────────────┘
                              │ Conformational Shift / Cleavage
┌─────────────────────────────▼───────────────────────────────┐
│  STACHEL SEQUENCE (Tethered Peptide Agonist)                │
│  - Mimicked / Triggered pharmacologically by AP503 or GL64   │
└─────────────────────────────┬───────────────────────────────┘
                              │
┌─────────────────────────────▼───────────────────────────────┐
│  SEVEN-TRANSMEMBRANE CORE (Cell Membrane)                   │
└─────────────────────────────┬───────────────────────────────┘
                              │
              Intracellular Gs-Protein Activation
                              │
                      Adenylyl Cyclase
                              │
                         cAMP Spikes
                              │
                    Protein Kinase A (PKA)
                              │
                ┌─────────────┴─────────────┐
                ▼                           ▼
        Nuclear β-Catenin           NFATC1 Inhibition
        (Drives Osteoblasts)        (Halts Osteoclasts)

At the core of the receptor's architecture is an autoproteolysis-inducing (GAIN) domain located just outside the cell membrane. Within this domain sits a hidden peptide segment termed the Stachel sequence (German for "stinger"). Under resting conditions, this stinger remains tucked within the receptor's structure. When the receptor experiences mechanical strain or engages its biological binding partner, protein tyrosine kinase 7 (PTK7), the physical force alters the GAIN domain's shape. This conformational shift frees the tethered Stachel sequence to bind the receptor's own transmembrane bundle, flipping the biochemical switch to "on".

The Leipzig and Shandong research teams determined that the synthetic compound AP503—alongside complementary work on small-molecule agonists such as GL64 by researchers in Shanghai and Leicester—functions as a chemical surrogate for this mechanical trigger. Rather than requiring violent physical force to displace the GAIN domain, AP503 slips into the transmembrane pocket, stabilizing the active signaling state.

Once activated, GPR133 couples to intracellular Gs proteins, triggering an immediate spike in cyclic adenosine monophosphate (cAMP) and activating protein kinase A (PKA). In osteoblasts, this cascade promotes the canonical Wnt/β-catenin signaling pathway. β-catenin escapes proteasomal destruction, translocates into the cell nucleus, and activates master osteogenic transcription factors, including Runx2 and Osterix (Sp7). This chain reaction forces immature mesenchymal stem cells and osteoprogenitors to differentiate into fully active osteoblasts, synthesizing type I collagen, alkaline phosphatase, and osteocalcin to assemble hard, mineralized bone matrix.

Simultaneously, the switch sends an inhibitory signal across the skeletal microenvironment. In osteoclasts—the multi-nucleated cells derived from hematopoietic lineages that dissolve bone by secreting hydrochloric acid and cathepsin K—receptor activation disrupts the transcription factor NFATC1 through the cAMP-PKA axis. At the same time, newly energized osteoblasts recalibrate their secretion of receptor activator of nuclear factor-κB ligand (RANKL) and osteoprotegerin (OPG), depriving developing osteoclasts of the signals needed to survive.

This simultaneous action solves a fundamental challenge in bone biology: the tight, unavoidable coupling between formation and resorption. In normal physiology, whenever a drug stimulates osteoblasts, those cells eventually signal osteoclasts to tear the new bone down. By controlling both pathways through a single receptor input, AP503 decouples this cycle, maintaining net structural synthesis without triggering a surge in bone-clearing activity.


The Therapeutic Impasse in Skeletal Medicine

For decades, the standard of care for metabolic bone disease has been defined by clear limitations. Existing clinical treatments fall into two broad classes: antiresorptive agents and anabolic agents. Neither group can safely, reliably, and permanently restore lost bone density in patients with advanced clinical disease.

Antiresorptive medications, dominated by oral and intravenous bisphosphonates (such as alendronate, risedronate, and zoledronic acid) alongside the monoclonal antibody denosumab, protect bone purely by stopping osteoclasts from clearing damaged tissue. While these drugs cut fracture rates in the initial years of use, they do not generate new bone matrix. Instead, they trap older bone tissue inside the skeleton.

Over prolonged treatment periods, the suppression of normal bone remodeling allows microcracks to accumulate, raising the long-term risk of atypical femoral fractures (AFF) and osteonecrosis of the jaw (ONJ). Furthermore, denosumab cannot be stopped without a rapid, severe rebound: withdrawing the drug triggers an explosion of osteoclast activity that rapidly strips bone mineral density and causes vertebral compression fractures within months.

┌───────────────────────────┬───────────────────────────────────┬────────────────────────────────────────┐
│ THERAPEUTIC CLASS         │ REPRESENTATIVE AGENTS             │ PRIMARY LIMITATIONS & SAFETY RISKS     │
├───────────────────────────┼───────────────────────────────────┼────────────────────────────────────────┤
│ Antiresorptive            │ Alendronate, Zoledronic Acid,     │ Does not build bone; freezes normal    │
│                           │ Denosumab                         │ remodeling; risk of atypical fractures,│
│                           │                                   │ jaw necrosis, and rebound bone loss    │
├───────────────────────────┼───────────────────────────────────┼────────────────────────────────────────┤
│ Anabolic                  │ Teriparatide (PTH 1-34),          │ Requires daily subcutaneous injections;│
│ (Hormone Agonists)        │ Abaloparatide (PTHrP analog)      │ 18-24 month lifetime cap; eventually   │
│                           │                                   │ triggers secondary bone breakdown      │
├───────────────────────────┼───────────────────────────────────┼────────────────────────────────────────┤
│ Dual-Action Sclerostin    │ Romosozumab                       │ Capped at 12 monthly doses; black-box  │
│ Inhibitor                 │                                   │ warning for heart attacks and strokes; │
│                           │                                   │ loses efficacy after 1 year            │
├───────────────────────────┼───────────────────────────────────┼────────────────────────────────────────┤
│ Adhesion GPCR Activator   │ AP503 / GL64                      │ Uncouples formation from resorption;   │
│ (Experimental)            │ (GPR133 / ADGRD1 agonists)        │ dual bone-muscle building; currently   │
│                           │                                   │ advancing through preclinical stages   │
└───────────────────────────┴───────────────────────────────────┴────────────────────────────────────────┘

Anabolic medications introduce a different set of challenges. Teriparatide and abaloparatide—peptide analogs of parathyroid hormone (PTH) and parathyroid hormone-related protein (PTHrP)—must be delivered via daily subcutaneous injections into the abdomen or thigh. These peptides bind the parathyroid hormone 1 receptor (PTH1R). While intermittent bursts of PTH1R signaling promote bone formation, prolonged exposure stimulates osteoclasts, closing the clinical "anabolic window" after approximately 18 to 24 months.

Romosozumab, an antibody targeting the Wnt pathway inhibitor sclerostin, builds bone rapidly while subduing resorption, but its anabolic effect plateaus after twelve monthly subcutaneous injections. More concerningly, it carries a black-box warning from the U.S. Food and Drug Administration due to elevated rates of myocardial infarction, stroke, and cardiovascular death observed in phase 3 clinical trials.

Because of these boundaries, finding a targeted therapy that can reverse severe osteoporosis without hormonal exhaustion or cardiovascular toxicity has remained an elusive objective in musculoskeletal pharmacology.

The Leipzig findings suggest that GPR133 acts without relying on the systemic endocrine routes used by PTH1R or the vascular targets tied to sclerostin inhibition. By directly addressing the local mechanosensitive receptors on osteoblasts, AP503 triggers anabolic bone repair while bypassing systemic calcium disruptions and vascular calcification risks.


Inside the Leipzig-Shandong Laboratory Trials

To establish the physiological necessity of GPR133 in bone remodeling, the researchers engineered two separate knockout mouse models: a constitutive knockout lacking GPR133 across all body tissues, and an osteoblast-specific conditional knockout removing the receptor exclusively from cells expressing the osteogenic transcription factor Osterix.

The results in both groups were stark. Animals stripped of GPR133 developed early-onset, severe osteopenia. High-resolution micro-computed tomography (micro-CT) imaging revealed profound skeletal degradation:

  • Cortical bone thickness across the femoral midshaft decreased by double-digit percentages, leaving thin, brittle outer bone walls.
  • Trabecular bone volume fraction (BV/TV) within the lumbar vertebrae and femoral epiphyses collapsed, accompanied by severe trabecular thinning and widespread loss of interconnected structural plates.
  • Dynamic bone histomorphometry using calcein double-labeling revealed a precipitous drop in the mineral apposition rate (MAR), confirming that osteoblasts had largely ceased laying down new mineralized layers.
  • Serum analysis tracked a marked decline in procollagen type I N-terminal propeptide (P1NP), a reliable biomarker of bone formation, alongside a sharp rise in C-terminal telopeptide of type I collagen (CTX), indicating unchecked osteoclastic bone resorption.

Biomechanically, femurs harvested from the knockout mice fractured under significantly lower peak loads in three-point bending assays. The receptor's absence was sufficient to induce the structural decay of advanced human osteoporosis in otherwise healthy, young animals.

                FEMORAL CROSS-SECTION (MICRO-CT ANALYSIS)
       ┌────────────────────────┐        ┌────────────────────────┐
       │   GPR133 KNOCKOUT /    │        │      AP503 TREATED     │
       │  UNMANAGED OSTEOPENIA  │        │   RECEPTOR ACTIVATED   │
       ├────────────────────────┤        ├────────────────────────┤
       │ ░░░ Thin Cortical Wall │        │ ████ Thick, Dense Bone │
       │                        │        │ ████ Outer Cortical    │
       │   ·  ·  ·   Fragmented │        │                        │
       │  ·    ·     Trabeculae │        │ ▓▓▓▓ Robust Inter-     │
       │     ·   ·   (High Void │        │ ▓▓▓▓ connected Lattice │
       │   ·   ·     Fraction)  │        │ ▓▓▓▓ (High BV/TV)      │
       │                        │        │                        │
       │ ░░░ High Fracture Risk │        │ ████ High Peak Bending │
       │     Low Peak Load      │        │      Tolerance         │
       └────────────────────────┘        └────────────────────────┘

The pivotal experimental test came when the researchers administered AP503 to mice whose ovaries had been surgically removed (ovariectomy), an established animal model mimicking the estrogen-depletion bone loss seen in postmenopausal women. Within this estrogen-deficient environment, bone turnover typically skews heavily toward destruction, melting away trabecular bone in a matter of weeks.

Daily administration of AP503 reversed this trajectory. The compound activated the GPR133 receptors remaining on the osteoblasts, stimulating mineral production and stabilizing skeletal density. Serum P1NP climbed while CTX dropped back toward baseline levels, demonstrating that the chemical had re-established an anabolic balance. Micro-CT scans of treated mice showed restored trabecular thickness, filled-in endocortical bone cavities, and significant improvements in bone mineral density.

When tested in wild-type mice without hormone deficiencies, AP503 produced bones that were thicker and denser than those of untreated control animals. Importantly, when the researchers administered AP503 to mice genetically engineered without GPR133, the compound had no effect, verifying that its anabolic action operates specifically through this receptor target rather than off-target pathways.

The team also uncovered an additive response when testing AP503 alongside physical exercise. Mice given access to treadmill running while receiving daily doses of AP503 showed substantially greater gains in bone volume and mechanical strength than animals exposed to either exercise or AP503 alone. Because GPR133 naturally functions as a mechanoreceptor, the physical force of exercise and the chemical activation of the drug worked through converging intracellular pathways, creating a potent combined stimulus for bone formation.


Bridging Bone and Muscle: Defeating Osteosarcopenia

The clinical promise of GPR133 reaches beyond bone remodeling. In an earlier series of studies, Liebscher and her colleagues discovered that GPR133 is prominently expressed across skeletal muscle tissue, where it helps regulate muscle fiber hypertrophy and contractile protein synthesis.

When the Leipzig team administered AP503 in muscle-wasting models, the compound stimulated muscle growth, increased cross-sectional muscle fiber area, and improved grip strength. The finding suggests the receptor switch can address two closely linked aging conditions simultaneously: osteoporosis (loss of bone density) and sarcopenia (loss of skeletal muscle mass and strength).

                     AP503 PHARMACOLOGICAL TARGETING
                                    │
                       GPR133 / ADGRD1 ACTIVATION
                                    │
               ┌────────────────────┴────────────────────┐
               ▼                                         ▼
     SKELETAL REMODELING                       SKELETAL MUSCLE FIBERS
  - Osteoblast differentiation ↑            - Protein synthesis acceleration
  - Type I collagen production ↑            - Fiber cross-sectional area ↑
  - Osteoclast resorption rates ↓           - Muscle contractile velocity ↑
               │                                         │
               ▼                                         ▼
      BONE ARCHITECTURE                        MUSCLE TISSUE INTEGRITY
  (Elevated Bending Threshold)              (Enhanced Balance & Force)
               │                                         │
               └────────────────────┬────────────────────┘
                                    ▼
                      CLINICAL FALL & FRACTURE REDUCTION
                    - Less frequent loss of footing
                    - Greater structural resistance during impact
                    - Prevention of catastrophic fragility fractures

In geriatric medicine, the co-occurrence of these conditions is classified as osteosarcopenia. Frail older adults do not break bones spontaneously during quiet rest; they suffer fractures when weak quadriceps, poor balance, and slow postural reflexes cause a fall onto a fragile hip or wrist.

Current medical therapies treat these issues as separate disorders: patients take bisphosphonates for their bones while relying on resistance exercise or physical therapy for their muscle wasting. An orally bioavailable therapy that strengthens muscle fibers while stimulating bone-forming cells could transform clinical management for bedridden patients, stroke victims undergoing rehab, and people with severe mobility limitations.

This dual capability could also address disuse osteopenia, where patients immobilized in casts or placed on prolonged bed rest lose bone mass at ten times the normal rate. Because GPR133 acts as a mechanical sensor, unloading bone causes the receptor to fall dormant, triggering tissue wasting. Delivering an agonist like AP503 provides the chemical signal of weight-bearing exercise even when mechanical movement is absent, potentially preserving muscle and bone integrity during periods of enforced bed rest or deep-space flight.


Independent Analysis and Scientific Scrutiny

Independent scientists have welcomed the Leipzig-Shandong discoveries, pointing out that adhesion GPCRs have long been neglected in drug development despite representing some of the most versatile signaling proteins in human biology.

"When we tested these bones, they turned out to be much stronger than usual," noted Dr. Thomas Ambrosi, an assistant professor of orthopedic surgery and bone stem cell biologist at the University of California, Davis, during an independent review of the biomechanical findings. Ambrosi emphasized that finding a small-molecule compound that increases bone mineral density while improving structural bone toughness is rare in preclinical musculoskeletal research.

At the same time, GPCR pharmacologists and clinical endocrinologists urge caution regarding the challenges of drug translation. Converting a research probe like AP503 into an approved human medicine requires clearing significant developmental hurdles:

  • Bioavailability and Chemical Optimization: AP503 was identified via computer-assisted screening as an early chemical proof-of-concept. In its current form, the molecule requires relatively high dosing concentrations in animal models. Medicinal chemists must systematically modify the scaffold to improve oral absorption, extend its biological half-life, and ensure it clears cleanly through liver and kidney metabolic pathways.
  • Receptor Selectivity across the Adhesion Family: The human body contains 33 distinct adhesion GPCRs governing everything from brain development (GPR56/ADGRG1) to lung function and immune response. A therapeutic designed to reverse severe osteoporosis must activate GPR133 selectively without off-target activity on closely related aGPCRs, which could trigger unexpected neurological, cardiovascular, or inflammatory side effects.
  • Long-Term Safety in Mineralized Tissues: Bone is a dynamic organ that requires continuous microscopic maintenance. Completely shutting down osteoclasts while over-stimulating osteoblasts for years risks causing osteopetrosis (pathologically dense, brittle bones) or ectopic mineralization in blood vessels and kidneys. Researchers must determine how to cycle the drug to stimulate bone formation without freezing normal repair processes.
  • Oncogenic Surveillance: Adhesion GPCRs, including GPR133, have been implicated in glioblastoma cell growth and tumor vascularization in specific cancer models. Delivering a systemic GPR133 agonist to older patients will require rigorous toxicology studies to prove the drug does not inadvertently promote tumor growth or support angiogenesis in occult malignancies.

Human genetics provides reassuring support for the target's physiological importance. Extensive genome-wide association studies (GWAS) analyzing hundreds of thousands of individuals have linked natural variations in the human ADGRD1 (GPR133) gene to differences in bone mineral density, cortical thickness, and adult height. These human data confirm that the Leipzig team's mouse findings reflect genuine human biology: individuals with less active GPR133 variants naturally develop lower peak bone mass and face a higher risk of early-onset skeletal fractures.


The Path to Human Trials

The transition of GPR133 agonists from mouse experiments into human clinical trials is being spearheaded by Leipzig University's Collaborative Research Centre 1423 (CRC 1423), a specialized research consortium funded by the German Research Foundation (DFG) dedicated entirely to structural analysis and therapeutic targeting of adhesion GPCRs.

                     TRANSLATIONAL DEVELOPMENT PIPELINE
┌────────────────────────────────────────────────────────────────────────┐
│ PHASE 0: Preclinical Discovery & Mechanistic Proof (COMPLETED)         │
│ - Target identification: GPR133 / ADGRD1 in osteoblasts & osteoclasts   │
│ - Knockout mouse phenotyping: confirmation of severe osteopenic state   │
│ - Small-molecule discovery: identification of AP503 via in silico dock  │
│ - Proof of concept: reversal of osteopenia in ovariectomized mice      │
└───────────────────────────────────┬────────────────────────────────────┘
                                    │
┌───────────────────────────────────▼────────────────────────────────────┐
│ PHASE 1: Chemical Optimization & IND-Enabling Studies (YEARS 1 - 2)    │
│ - Structure-Activity Relationship (SAR) studies to optimize AP503       │
│ - ADME profiling: testing oral bioavailability, clearance, metabolism   │
│ - Safety toxicology in non-rodent mammalian models                     │
│ - Comprehensive screen against all 33 human adhesion GPCR family members│
└───────────────────────────────────┬────────────────────────────────────┘
                                    │
┌───────────────────────────────────▼────────────────────────────────────┐
│ PHASE 2: Phase 1 Human Clinical Safety Trials (YEARS 3 - 4)            │
│ - First-in-human healthy volunteer dose-escalation cohorts             │
│ - Pharmacokinetics, tolerability, and cardiac/vascular safety markers  │
│ - Early serum biomarker tracking: dynamic P1NP and CTX-1 alterations    │
└───────────────────────────────────┬────────────────────────────────────┘
                                    │
┌───────────────────────────────────▼────────────────────────────────────┐
│ PHASE 3: Phase 2/3 Clinical Efficacy Trials (YEARS 5+)                 │
│ - Postmenopausal women with high-risk, treatment-refractory disease    │
│ - Glucocorticoid-induced secondary osteoporosis cohorts                │
│ - Endpoints: Dual-energy X-ray absorptiometry (DEXA) BMD gains,        │
│   high-resolution peripheral quantitative CT, fragility fracture drops │
└────────────────────────────────────────────────────────────────────────┘

The researchers are running systematic structure-activity relationship (SAR) medicinal chemistry programs to refine the AP503 backbone. By introducing targeted chemical modifications, the team aims to build a nanomolar-affinity compound capable of convenient once-daily oral dosing, bypassing the daily injections required by teriparatide and abaloparatide.

The clinical development roadmap will follow a phased regulatory trajectory:

  1. Safety and Pharmacokinetics: Early Phase 1 trials in healthy postmenopausal volunteers will evaluate single- and multiple-ascending doses, monitoring drug tolerability, cardiovascular safety, and changes in serum bone turnover markers (P1NP, osteocalcin, and CTX-1).
  2. Target Populations: Phase 2 trials will recruit patients with advanced disease who have failed or exhausted existing therapies—such as postmenopausal women who have completed a 12-month course of romosozumab or two years of teriparatide but remain at severe risk of fracture.
  3. Secondary Indications: In parallel, researchers plan to evaluate GPR133 activators in patients with glucocorticoid-induced osteoporosis, where long-term steroid treatments for autoimmune diseases shut down natural osteoblast production and cause rapid, devastating bone loss.

If these compounds demonstrate the same anabolic potency and safety profile in human clinical trials that they showed in preclinical models, targeting the GPR133 receptor could shift clinical practice away from merely halting bone breakdown.

Instead of accepting skeletal decline as an irreversible reality of human aging, clinicians may soon have a practical medical tool: a targeted oral compound that turns on the body's bone-building machinery, reconstructs lost skeletal framework, and works to reverse severe osteoporosis from within the bone itself.

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