Lidocaine Reduces Pain and Anxiety From Peripheral IV Cannula Insertion

      Injected buffered lidocaine or lidocaine cream can reduce the pain and anxiety associated with intravenous cannula insertion, according to study findings reported in the August issue of the Annals of Emergency Medicine. Between the two, injected lidocaine is more effective in alleviating pain.
        Many patients who present to the emergency department require placement of a peripheral IV line, which frequently causes pain and anxiety, Dr. Candace McNaughton, from Vanderbilt University, Nashville, Tennessee, and colleagues note.
       Most IV placements in the ER are done without local anesthesia, the researchers point out. This may be due to "time constraints, difficulty with their application, perceived ineffectiveness, a belief that use of local anesthesia makes it more difficult to place IVs, or a belief by healthcare providers that the pain of IV insertion is insignificant."
     Research has shown that both the pain and anxiety of IV insertion can be reduced by pretreatment with local anesthetics, but the best method was unclear. Anesthetic creams are often used to reduce pain during IV insertion. However, in a busy ER setting, their usefulness is limited due to their delayed onset of action, the authors note. By contrast, injected anesthetics have a more rapid onset, but require an additional needle stick.
     In a randomized, crossover study, Dr. McNaughton's team compared pin and anxiety in 70 medical students or nurses who had IVs placed after pretreatment with injected buffered lidocaine, lidocaine cream, or no analgesia. A 10-point numeric rating scale was used to assess pain, anxiety, and treatment preference immediately following IV insertion.
     The median pain scores with lidocaine cream and injected, buffered lidocaine were 3 and 1, respectively. Without analgesia, the pain was much worse with a median score of 7. Similarly, the median anxiety score with both lidocaine treatments was 2 compared with a score of 4 without analgesia. The pretreatment method had no bearing on the likelihood of success, the report indicates, and most of the IV placement attempts were successful.
     When surveyed, 70% of the subjects indicated that they would always request injected, buffered lidocaine for themselves and for their patients undergoing IV insertion. Lidocaine cream was the preferred treatment for 26% of subjects and no analgesia for 4%.

Ann Emerg Med. 2009;54:214-220.
News Author: Anthony J. Brown, MD
CME Author: Laurie Barclay, MD

Ketamine May Be Useful for Intubation in Critically Ill Patients

Ketamine is a safe, valuable alternative to conventional etomidate for use as a sedative during intubation in critically ill patients, according to the results of a randomized controlled, single-blind trial reported online in the July 1 issue of The Lancet.

"Critically ill patients often require emergency intubation," write Patricia Jabre, MD, and colleagues from the KETASED Collaborative Study Group. "The use of etomidate as the sedative agent in this context has been challenged because it might cause a reversible adrenal insufficiency, potentially associated with increased in-hospital morbidity. We compared early and 28-day morbidity after a single dose of etomidate or ketamine used for emergency endotracheal intubation of critically ill patients."

At 12 emergency medical services or emergency departments and 65 intensive care units in France, 655 patients requiring sedation for emergency intubation were prospectively enrolled and randomly assigned by a computerized random-number generator list to receive 0.3 mg/kg of etomidate (n = 328) or 2 mg/kg of ketamine (n = 327) for intubation. Group assignment was known to only the emergency medicine physician enrolling patients.

The main outcome measure was the maximal score of the sequential organ failure assessment (SOFA) during the first 3 days in the intensive care unit. Analysis was by modified intent-to-treat, with exclusion from analysis of patients who died before reaching the hospital and those discharged from the intensive care unit earlier than 3 days.

Data were analyzed for 234 patients in the etomidate group and 235 in the ketamine group. Both groups had statistically similar mean maximal SOFA scores (10.3 ± 3.7 for etomidate vs 9.6 ± 3.9 for ketamine; mean difference, 0.7; 95% confidence interval [CI], 0.0 - 1.4; P = .056). Both groups had a median intubation difficulty score of 1 (interquartile ratio, 0 - 3; P = .70) suggesting similar intubation conditions.

Compared with the ketamine group, the etomidate group had a significantly higher percentage of patients with adrenal insufficiency (odds ratio, 6.7; 95% CI, 3.5 - 12.7). No serious adverse events occurred with either study drug.

"Our results show that ketamine is a safe and valuable alternative to etomidate for endotracheal intubation in critically ill patients, and should be considered in those with sepsis," the study authors write.

Limitations of this study include possibly insufficient power to show a significant increase in morbidity rates associated with etomidate use in patients with sepsis.

In an accompanying comment, Dr. Volker Wenzel and Dr. Karl H. Lindner, from Innsbruck Medical University in Innsbruck, Austria, note that successful emergency intubation of critically ill patients depends on pharmacologic knowledge as well as manual skills and clinical experience. Unfortunately, tightening regulations of the European Union hinder trials of commercially noninteresting pathology such as multiple trauma.

"We should be lobbying our parliamentary representatives to help with non-commercial research, otherwise industry lobbyists will continue pushing for rules that only global drug companies can comply with," Drs. Wenzel and Lindner write. "Should that occur, our fate would be similar to physicians in developing countries, who have many questions about optimising health care but cannot do clinical trials to find valid answers."

The French Ministry of Health supported this study. The study authors and editorialists have disclosed no relevant financial relationships. 

Lancet. Published online July 1, 2009.

Cardiac Arrest Picu Kematian Michael Jackson

BINTANG pop Michael Jackson meninggal di usia 50 tahun akibat cardiac arrest. Stasiun TV Los Angeles KTLA melaporkan bahwa Los Angeles fire officials sempat merespon panggilan 911 dari rumah Jackson. Tapi, Jakson sudah tidak bernafas lagi saat petugas tiba di sana. Para medis melakukan prosedur darurat medis (Cardiopulmonary resuscitation/CPR) dan melarikannya ke UCLA Medical Center. Meskipun rumah sakit tidak membeberkan detail kondisi Jackson, dia dinyatakan meninggal akibat cardiac arrest. Apa beda cardiac arrest dengan serangan jantung?

Menurut Douglas Zipes, MD, MACC, seorang profesor dari Indiana University School of Medicine, dalam cardiac arrest, jantung berhenti bekerja dengan benar. Cardiac arrest, menurut Zipes, berbeda dengan serangan jantung, tapi bisa terjadi akibat serangan jantung. Cardiac arrest, merupakan gangguan ritme jantung saat bilik jantung bagian bawah, berdetak sangat cepat, 4-600 kali dalam semenit.

Ritme jantung ini, lantut Zipes, mencegah kontraksi bilik jantung bagian bawah dan menghambat pemompaan darah ke otak dan ke seluruh bagian tubuh. Dan, jika tidak segera diatasi bisa mengakibatkan kematian dalam waktu 4-5 menit.

Saat terjadi gangguan ritme jantung, terang Zipes, bilik jantung bagian bawah sama seperti sekantung cacing yang sudah tidak lagi efektif menekan. Akibatnya tidak ada darah yang dipompa ke seluruh bagian tubuh. Dan jika tidak ada oksigen dalam pembuluh darah yang bisa dipompa ke otak, maka otak akan segera mati.

CPR, menurut Zipes, bisa membantu agar darah tetap mengalir. Tapi diperlukan kejutan listrik ke jantung, baik dari alat penyalur listrik dari luar maupun peralatan internal jantung, untuk mengejutkan jantung agar kembali ke ritme normal."Beberapa aliran darah harus distimulusi, baik dengan CPR atau dengan alat pengejut untuk mengembalikan jantung ke fungsi normal," ujar Zipes, seperti dikutip situs webmd.

Menurut Zipes, 30-50% kasus cardiac arrest merupakan manifestasi dari penyakit jantung yang belum kelihatan. Jadi, Anda mungkin tidak akan merasakan rasa sakit di dada, sulit bernapas. Anda mungkin tidak merasakan gejala apapun.

Infants With Fetal Distress Are Most Affected by General Anesthesia for Cesarean Delivery

The infants most affected by general anesthesia for cesarean delivery are those who are already compromised in utero, according to the results of a study reported in the April 29 Online First issue of BMC Medicine. Anaesthesia guidelines recommend regional anaesthesia for most caesarean sections due to the risk of failed intubation and aspiration with general anaesthesia," write Charles S. Algert, from Kolling Institute of Medical Research, University of Sydney in Sydney, Australia, and colleagues. However, general anaesthesia is considered to be safe for the foetus, based on limited evidence, and is still used for caesarean sections. The study cohort consisted of 50,806 infants delivered by cesarean delivery from 1998 to 2004 for indications of planned subsequent cesarean delivery, failure to progress, or fetal distress. The investigators compared outcomes of neonatal intubation and 5-minute Apgar scores of less than 7 for deliveries performed with the mother under general anesthesia vs those performed with the mother under spinal or epidural anesthesia. For all 3 indications and across all levels of hospital, the risk for adverse outcomes was increased for cesarean deliveries performed with the patient under general anesthesia. Low-risk, planned subsequent cesarean deliveries had the largest relative risks for resuscitation with intubation (relative risk, 12.8; 95% confidence interval [CI], 7.6 - 21.7), and for Apgar scores of less than 7 (relative risk, 13.4; 95% CI, 9.2 - 19.4). Unplanned cesarean deliveries because of fetal distress had the largest absolute increase in risk (5 extra intubations per 100 deliveries and 6 extra Apgar scores <>

The Australian National Health and Medical Research Council supported this study. The study authors have disclosed no relevant financial relationships.
BMC Med. Published online April 29, 2009.

Incidence of and risk factors for awareness during anaesthesia.

Explicit recall of events during general anaesthesia is detected by direct questioning, as patients may not report awareness spontaneously or if they are questioned non-specifically. More than one interview is needed and credibility of reports should always be verified. The overall incidence of awareness has decreased over the last 40 years and is now 0.1-0.2%. Prospective study of patients who undergo general anaesthesia is the only valid method for determining the incidence of awareness. Studies of patients recruited through referrals by colleagues or advertisements, studies of compensation claims and those carried out through quality improvement systems are inadequate. Several factors increase the risk of awareness, including light anaesthesia, some types of surgery, a history of awareness, chronic use of central nervous system depressants, younger age, obesity, inadequate or misused anaesthesia delivery systems, insufficient knowledge about awareness, and ignoring the use of electroencephalographic monitors when the risk is otherwise increased.

Ghoneim MM.

Department of Anesthesia, University of Iowa, Iowa City, IA 52244, USA. mohamed-ghoneim@uiowa.edu

Kapan transfusi sel darah merah dilakukan?

• Transfusi sel darah merah hampir selalu diindikasikan pada kadar Hemoglobin (Hb) <7 g/dl, terutama pada anemia akut. Transfusi dapat ditunda jika pasien asimptomatik dan/atau penyakitnya memiliki terapi spesifik lain, maka batas kadar Hb yang lebih rendah dapat diterima. (Rekomendasi A)
• Transfusi sel darah merah dapat dilakukan pada kadar Hb 7-10 g/dl apabila ditemukan hipoksia atau hipoksemia yang bermakna secara klinis dan laboratorium.
(Rekomendasi C)
• Transfusi tidak dilakukan bila kadar Hb ≥10 g/dl, kecuali bila ada indikasi tertentu, misalnya penyakit yang membutuhkan kapasitas transport oksigen lebih tinggi (contoh: penyakit paru obstruktif kronik berat dan penyakit jantung iskemik berat).
(Rekomendasi A)
• Transfusi pada neonatus dengan gejala hipoksia dilakukan pada kadar Hb ≤11 g/dL; bila tidak ada gejala batas ini dapat diturunkan hingga 7 g/dL (seperti pada anemia bayi prematur). Jika terdapat penyakit jantung atau paru atau yang sedang membutuhkan suplementasi oksigen batas untuk memberi transfusi adalah Hb ≤13 g/dL.
(Rekomendasi C)

Pain Control After Surgery

What is Pain?

Pain is an uncomfortable feeling that tells you something may be wrong in your body. Pain is your body's way of sending a warning to your brain. Your spinal cord and nerves provide the pathway for messages to travel to and from your brain and the other parts of your body.

Receptor nerve cells in and beneath your skin sense heat, cold, light, touch, pressure, and pain. You have thousands of these receptor cells, most sense pain and the fewest sense cold. When there is an injury to your body -- in this case surgery -- these tiny cells send messages along nerves into your spinal cord and then up to your brain. Pain medicine blocks these messages or reduces their effect on your brain.

Sometimes pain may be just a nuisance, like a mild headache. At other times, such as after an operation, pain that doesn't go away -- even after you take pain medicine -- may be a signal that there is a problem. After your operation, your nurses and doctors will ask you about your pain because they want you to be comfortable, but also because they want to know if something is wrong. Be sure to tell your doctors and nurses when you have pain.
Purpose of this Booklet

This booklet talks about pain relief after surgery. It explains the goals of pain control and the types of treatment you may receive. It also shows you how to work with your doctors and nurses to get the best pain control.
Reading the booklet should help you:
Learn why pain control is important for your recovery as well as your comfort.
Play an active role in choosing among options for treating your pain.

Treatment Goals

People used to think that severe pain after surgery was something they "just had to put up with." But with current treatments, that's no longer true. Today, you can work with your nurses and doctors before and after surgery to prevent or relieve pain.

Pain control can help you:
Enjoy greater comfort while you heal.
Get well faster. With less pain, you can start walking, do your breathing exercises, and get your strength back more quickly. You may even leave the hospital sooner.
Improve your results. People whose pain is well-controlled seem to do better after surgery. They may avoid some problems (such as pneumonia and blood clots) that affect others.

Pain Control: What Are the Options?

Both drug and non-drug treatments can be successful in helping to prevent and control pain. The most common methods of pain control are described below. You and your doctors and nurses will decide which ones are right for you. Many people combine two or more methods to get greater relief.

Don't worry about getting "hooked" on pain medicines. Studies show that this is very rare -- unless you already have a problem with drug abuse.

Anesthesia machine in Asri Medical Centre Yogyakarta

The model of intensive care unit room

The five elements of the First Global Patient Safety Challenge

1. Blood safety
2. Injection and immunization safety
3. Safe clinical procedures
4. Safe water and sanitation in health care
5. Hand Hygiene

Hypokalemia

Background

Potassium is one of the body's major ions. Nearly 98% of the body's potassium is intracellular. The ratio of intracellular to extracellular potassium is important in determining the cellular membrane potential. Small changes in the extracellular potassium level can have profound effects on the function of the cardiovascular and neuromuscular systems.

The kidney determines potassium homeostasis, and excess potassium is excreted in the urine.The reference range for serum potassium level is 3.5-5 mEq/L, with total body potassium stores of approximately 50 mEq/kg (ie, approximately 3500 mEq in a 70-kg person).Hypokalemia is defined as a potassium level less than 3.5 mEq/L. Moderate hypokalemia is a serum level of 2.5-3 mEq/L. Severe hypokalemia is defined as a level less than 2.5 mEq/L.

Pathophysiology

Hypokalemia may result from conditions as varied as renal or GI losses, inadequate diet, transcellular shift (movement of potassium from serum into cells), and medications.

History

The history may be vague. Hypokalemia should be suggested by a constellation of symptoms that involve the GI, renal, musculoskeletal, cardiac, and nervous systems. The patient's medications should be reviewed to ascertain whether any of them could cause hypokalemia. Common symptoms include the following:

• Palpitations
• Skeletal muscle weakness or cramping
• Paralysis, paresthesias
• Constipation
• Nausea or vomiting
• Abdominal cramping
• Polyuria, nocturia, or polydipsia
• Psychosis, delirium, or hallucinations
• Depression

Physical

Findings may include the following:

• Signs of ileus
• Hypotension
• Ventricular arrhythmias
• Cardiac arrest
• Bradycardia or tachycardia
• Premature atrial or ventricular beats
• Hypoventilation, respiratory distress
• Respiratory failure
• Lethargy or other mental status changes
• Decreased muscle strength, fasciculations, or tetany
• Decreased tendon reflexes
• Cushingoid appearance (eg, edema)

Causes

• Renal losses
• Renal tubular acidosis
• Hyperaldosteronism
• Magnesium depletion
• Leukemia (mechanism uncertain)
• GI losses
• Vomiting or nasogastric suctioning
• Diarrhea
• Enemas or laxative use
• Ileal loop
• Medication effects
• Diuretics (most common cause)
• Beta-adrenergic agonists
• Steroids
• Theophylline
• Aminoglycosides
• Transcellular shift
• Insulin
• Alkalosis
• Malnutrition or decreased dietary intake, parenteral nutrition

What is the treatment for low potassium?

Serum potassium levels above 3.0 mEq/liter are not considered dangerous or of great concern; they can be treated with potassium replacement by mouth. Levels lower than 3.0 mEq/liter may require intravenous replacement. Decisions are patient-specific and depend upon the diagnosis, the circumstances of the illness, and the patient's ability to tolerate fluid and medication by mouth.

Over the short term, with self-limited illnesses like gastroenteritis with vomiting and diarrhea, the body is able to regulate and restore potassium levels on its own. However, if the hypokalemia is severe, or the losses of potassium are predicted to be ongoing, potassium replacement or supplementation may be required.

In those patients taking diuretics, often a small amount of oral potassium may be prescribed since the loss will continue as long as the medication is prescribed. Oral supplements may be in pill or liquid form, and the dosages are measured in mEq. Common doses are 10-20mEq per day. Alternatively, consumption of foods high in potassium may be suggested for replacement. Bananas, apricots, oranges, and tomatoes are high in potassium content. Since potassium is excreted in the kidney, blood tests that monitor kidney function may be ordered to predict and prevent potassium levels from rising too high.

When potassium needs to be given intravenously, it must be given slowly. Potassium is irritating to the vein and must be given at a rate of approximately 10 mEq per hour. As well, infusing potassium too quickly can cause heart irritation and promote potentially dangerous rhythms like ventricular tachycardia.

The Medical Benefits Of Fluorinated Anesthetics by Stephanie Larkin

Although there may be many other variations today, there are a few main types of fluorinated anesthetics. They are sevoflurane, desflurane, and isoflurane. Although we will not go into detail on the various types of fluorinated anesthetics, each possess characteristics that may not be found in the others. However there is little research that would indicate a particular preference.

It's a little known fact, but fluorinated anesthetics have been around for over 40 years and some argue that they revolutionized standard operating practices. Fluorinated anesthetics were initially used over traditional anesthetics because they are inflammable. Before fluorinated anesthetics fires were pretty common in an operating room. Fortunately fires within the operating are no longer a major issue, yet studies have shown that there are many new benefits of this particular type of anesthetic.

Fluorinated anesthetics have been known to come upon patients rapidly and with ease. Typically these anesthetics render patients unconscious through inhalation. This technique is considered more practical and simplistic versus anesthetics that must be injected. Although fluorinated anesthetics can be administered through an IV, usually, these anesthetics must be breathed and re-breathed and since fluorinated anesthetics are odorless getting patients to inhale is easy. And, due to breathing and re-breathing, administering the anesthesia is fairly simple. Hospital staff and patients don't have to deal with the issues generated other anesthetics such the tubes getting in the way or restricting movement.

Studies have also shown that patients that are given fluorinated anesthetics experience fewer if any side effects as a result of use. Before the use of fluorinated anesthetics, patients would commonly suffer side effects such as nausea or vomiting as a result of the anesthesia. Fluorinated anesthetics have been proven to be safe in children, pregnant women, and the elderly.

Fluorinated anesthetics are also said to relax the muscles. This benefit is probably the one that most are familiar with as this feature allows patients t be calm and relaxed even before the actual surgery. For most people, surgery is a nerve wrecking ordeal and often anxieties cause the body to react in ways that are not ideal for surgery. For example, the patients may have a slightly higher blood pressure than normal or start to shake uncontrollably.

Another benefit would be the quick recovery time patients experience versus other anesthetics. Although there are conflicting studies on how quickly patients who were given fluorinated anesthetics were able to recover before those who were given other types of anesthetics. Typically, the research has shown that patients recover somewhere between 3-10 minutes sooner. And, many patients began to recover as soon as they are allowed to inhale and exhale naturally. So, in essence once the patient begins to exhale, they can start to regain consciousness. Unlike many other types of anesthesia, fluorinated anesthetics have also been know to allow patients to be alert, instead fling lingering grogginess and disorientation.

For the hospital, fluorinated anesthetics are much more economical choice over other anesthetics. There are no special storing requirements and these types of anesthetics have a longer shelf life than many of their counterparts. Also, there is no need to for the hospital to purchase any additional equipment, as fluorinated anesthetics are easy to transport; and, their effect on patients can be monitored with existing equipment. Although it has not been researched, there is a good chance that fluorinated anesthetics have also played apart in the development of surgical procedures being performed in a more time effective manner. Since the onset for these anesthetics are rapid and the recover is quicker, surgeries such as outpatient procedures are probably completed in a much more swiftly. Thus, allowing more procedures to be scheduled.

It should be noted that patients will react to any type of anesthesia differently, and you may wish to consult with an anesthesiologist if you will be having a surgical procedure performed. There is no doubt that fluorinated anesthetics have changed the landscape of surgical procedures. And. The benefits for these anesthetics can be seen by both quantitative and qualitative measures, from the money saved to the quality of patient care during surgery. Yet despite the fact and figures, being able to efficiently and effective treat patients is what matters most.

What is an Intensive Care Unit?

Each year in New South Wales, thousands of patients are admitted into Intensive Care Units (ICUs). These units are designed to deliver the highest of medical and nursing care to the sickest of patients. Some smaller rural and urban hospitals do not have intensive care units whilst larger metropolitan hospitals may have a number of specialised intensive care units.

History

During the 1960’s and early 1970’s doctors recognised the life-saving potential of placing patients into specialised areas called Intensive Care Units. The purpose of the units was to provide more intensive management for patients following major injury, illness or after major surgery.

First Impressions of an Intensive Care Unit

Physically, most ICUs are large areas with a concentration of specialised, technical equipment and monitors needed to care for the critically ill. Access to the unit is often limited, not only to families but also to other non-ICU staff members. The ICU has a larger ratio of doctors and nurses to patients than found in other areas of the hospital.

Every patient in ICU has a monitor (a television-like screen) that can monitor the patient's heart rate and rhythm, blood pressure, temperature, breathing and many other things. Most patients will have powerful drugs given to them continuously through intravenous infusions (‘I.V’ or ‘drip’). Patients may also be assisted in their breathing by a machine (ventilator). They are attached to the machine by a tube inserted into the trachea (windpipe).

For most families of ICU patients there is no previous knowledge of intensive care equipment and procedures. The business of a unit can be frightening. One of the most concerning aspects of being in the ICU is the alarms. They seem to go off regularly and come from all around. Almost all ICU equipment uses alarms. However, it is important to remember that most alarms do not signal an emergency, but rather, they assist staff in providing better care by letting the staff know that the patient needs closer attention.

Visiting Family in the Intensive Care Unit

Visiting in most units is restricted in the interests of both patient and family safety and to allow staff to continue the high intensity care required. Children of the patient may be allowed to visit. We recommend discussion with a senior registered nurse or a social worker as to how this visit may affect your child. Visiting hours are usually during the daytime with some units having a ‘quiet-time’ (no visitors) during the middle of the day. Exceptions to these general rules may be made in consultation with senior ICU nursing and medical staff. At times there may be some special requirements to control infection.

Pain Relief In Labour

              Though labour is a normal physiological process, it is associated with some amount of pain. Pain is a very subjective phenomena and dependent on the individual. It depends on many factors like the person’s physical build, her emotional status, her mental outlook, associated and coincidental problems etc. Since there are so many factors that influences pain perception, pain relief can be achieved by changing some or all these factors.
               Labour analgesia was first practiced way back in 1847 when chloroform was used by a Scottish physician called James Simpson. The only problem was that the woman woke up 3 days after the delivery and refused to believe that she had delivered.Later on prominent people like Queen Victoria also did experience “Painless Labour”.
               During that time it was believed that to opt for painless labour was immoral. The justification was that labour pain was punishment to the woman for Eve’s indiscretion in Eden. But this is a thing of the past and more and more people are going in for pain relief during labour by either medications or other forms of therapy.
               There is madication for painless labour like epidural and spinal anaesthesia: This type of medication is by far the most popular or commonly followed method. Both are nearly similar but Epidural is preferred for a variety of technical reasons. In Epidural anesthesia / analgesia, a local anaesthetic agent is injected inside the vertebral column in the region of the lower back. This reduces the backache and abdominal pain during labour. The doctor may inject the local anaesthetic by a special needle (single shot EA) or more preferably, pass a thin plastic tube into the vertebral column through the needle. The needle is removed and the plastic tube kept in place.
              Local anaesthetic agent is injected through this plastic tube at periodic intervals depending upon the need of the patient – no matter how long the labour. The catheter is kept for some time after delivery and then removed. This can also be used to give anaesthesia during Caesarean section. For further details regarding the same, it is best to approach your doctor who can then manage a meeting with the hospital anesthetist, so that all your doubts regarding the technique can be cleared.

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