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Emmanuel M, Margolis R, Badh R, Kachroo N, Teach SJ, Parikh K. Caregiver Language Preference and Health Care Utilization Among Children With Asthma. Pediatrics 2023; 152:e2023061869. [PMID: 37964708 DOI: 10.1542/peds.2023-061869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Asthma is a leading cause of health care utilization in children and disproportionately affects historically marginalized populations. Yet, limited data exist on the role of caregiver language preference on asthma morbidity. The study aim was to determine whether caregiver non-English language preference (NELP) is associated with unscheduled asthma-related health care utilization in pediatric patients. METHODS This was a retrospective cohort study using data from a population-level, disease-specific registry of pediatric patients with asthma living in the District of Columbia (DC). Patients aged 2 to 17 years were included and the study period was 2019. The primary exposure variable was language preference: English preferred (EP) or NELP by self-identified language preference. The primary outcome was unscheduled asthma-related health care utilization including emergency department visits, hospitalizations (ICU and non-ICU), and ICU visits alone. Logistic regression was used to calculate adjusted odds ratios (aORs). RESULTS Of the 14 431 patients included, 8.1% had NELP (1172 patients). In analyses adjusted for age, sex, ethnicity, insurance status, diagnosis of persistent asthma, controller prescription, and encounter with a primary care provider, caregiver NELP was associated with an increased odds of having an asthma-related emergency department visit (aOR, 1.37; 95% CI, 1.08-1.74), hospitalization (aOR, 1.79; 95% CI, 1.18-2.72), and ICU visit (aOR, 4.37; 95% CI, 1.93-9.92). In the Hispanic subgroup (n = 1555), caregiver NELP was associated with an increased odds of having an asthma-related hospitalization (aOR, 1.73; 95% CI, 1.02-2.93). CONCLUSIONS In the population of children in the District of Columbia with asthma, caregiver NELP was associated with increased odds of asthma-related health care utilization, suggesting that caregiver language preference is a significant determinant of asthma outcomes.
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Affiliation(s)
| | | | | | | | - Stephen J Teach
- Division of Emergency Medicine
- Center for Translational Research
| | - Kavita Parikh
- Center for Translational Research
- Division of Hospital Medicine, Children's National Hospital, Washington, District of Columbia
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Implementation strategies in emergency management of children: A scoping review. PLoS One 2021; 16:e0248826. [PMID: 33761525 PMCID: PMC7990517 DOI: 10.1371/journal.pone.0248826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 03/07/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Implementation strategies are vital for the uptake of evidence to improve health, healthcare delivery, and decision-making. Medical or mental emergencies may be life-threatening, especially in children, due to their unique physiological needs when presenting in the emergency departments (EDs). Thus, practice change in EDs attending to children requires evidence-informed considerations regarding the best approaches to implementing research evidence. We aimed to identify and map the characteristics of implementation strategies used in the emergency management of children. METHODS We conducted a scoping review using Arksey and O'Malley's framework. We searched four databases [Medline (Ovid), Embase (Ovid), Cochrane Central (Wiley) and CINAHL (Ebsco)] from inception to May 2019, for implementation studies in children (≤21 years) in emergency settings. Two pairs of reviewers independently selected studies for inclusion and extracted the data. We performed a descriptive analysis of the included studies. RESULTS We included 87 studies from a total of 9,607 retrieved citations. Most of the studies were before and after study design (n = 68, 61%) conducted in North America (n = 63, 70%); less than one-tenth of the included studies (n = 7, 8%) were randomized controlled trials (RCTs). About one-third of the included studies used a single strategy to improve the uptake of research evidence. Dissemination strategies were more commonly utilized (n = 77, 89%) compared to other implementation strategies; process (n = 47, 54%), integration (n = 49, 56%), and capacity building and scale-up strategies (n = 13, 15%). Studies that adopted capacity building and scale-up as part of the strategies were most effective (100%) compared to dissemination (90%), process (88%) and integration (85%). CONCLUSIONS Studies on implementation strategies in emergency management of children have mostly been non-randomized studies. This review suggests that 'dissemination' is the most common strategy used, and 'capacity building and scale-up' are the most effective strategies. Higher-quality evidence from randomized-controlled trials is needed to accurately assess the effectiveness of implementation strategies in emergency management of children.
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Shelef DQ, Badolato GM, Badh R, Owotomo O, Kachroo N, Weissman M, Teach SJ, Shah AY. Creation and validation of a citywide pediatric asthma registry for the District of Columbia. J Asthma 2021; 59:901-909. [PMID: 33635727 DOI: 10.1080/02770903.2021.1895213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To create and validate a citywide pediatric Asthma Registry to improve the care and outcomes of children and adolescents in Washington, DC through data-driven quality improvement (QI). METHODS All available electronic health record data from inpatient and outpatient domains of Children's National Hospital were aggregated from an existing enterprise data warehouse. Inclusion criteria included asthma relevant ICD-10 codes over the prior 24 months. Available Asthma Registry measures include patient demographics, ambulatory visits, hospital admissions, persistent asthma diagnoses, and prescription of controller medications. Data capture was validated using US Census data and current asthma prevalence estimate of the Behavioral Risk Factor Surveillance System (BRFSS). RESULTS The registry identified 15,991 DC children and adolescents with asthma aged 0-17 years, inclusive, at the end of 2020. This was 14.2% higher than the estimate of 14,001 children derived from BRFSS. Characteristics of those in the registry included: mean age of 9.5 (1.4) years, 57.9% male, 72.3% Black, and 66.7% publicly insured. Over the prior 24 months, 30.3% had ≥1 emergency department visit, and 10.5% had ≥1 hospital admission. Controller medications were prescribed for 59.6% of children with persistent asthma. Rates varied by sampled primary care practice sites. CONCLUSIONS A population-level pediatric asthma registry captures more children and adolescents with asthma in DC then a BRFSS-derived estimate, and provides city-wide measures of asthma-related utilization. The registry allows for stratification by primary care practice locations and asthma characteristics, supporting the design, implementation, and evaluation of QI projects at the practice, health system, and population levels. Supplemental data for this article can be accessed at publisher's website.
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Affiliation(s)
- Deborah Q Shelef
- Children's National Hospital, Washington, DC, USA.,University of Maryland School of Public Health, College Park, MD, USA
| | | | - Ranjodh Badh
- Children's National Hospital, Washington, DC, USA
| | | | | | - Mark Weissman
- Children's National Hospital, Washington, DC, USA.,George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Stephen J Teach
- Children's National Hospital, Washington, DC, USA.,George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Ankoor Y Shah
- District of Columbia Department of Health, Washington, DC, USA
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Shah AY, Dooley D, Shelef DQ, Patel SJ. Improving Asthma Outcomes in Children: From the Emergency Department and Into the Community. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Bee P, Pedley R, Rithalia A, Richardson G, Pryjmachuk S, Kirk S, Bower P. Self-care support for children and adolescents with long-term conditions: the REfOCUS evidence synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BackgroundSelf-care support (e.g. education, training, peer/professional support) is intended to enhance the self-care capacities of children and young people, while simultaneously reducing the financial burden facing health-care systems.ObjectivesTo determine which models of self-care support for long-term conditions (LTCs) are associated with significant reductions in health utilisation and costs without compromising outcomes for children and young people.DesignSystematic review with meta-analysis.PopulationChildren and young people aged 0–18 years with a long-term physical or mental health condition (e.g. asthma, depression).InterventionSelf-care support in health, social care, educational or community settings.ComparatorUsual care.OutcomesGeneric/health-related quality of life (QoL)/subjective health symptoms and health service utilisation/costs.DesignRandomised/non-randomised trials, controlled before-and-after studies, and interrupted time series designs.Data sourcesMEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, ISI Web of Science, NHS Economic Evaluation Database, The Cochrane Library, Health Technology Assessment database, Paediatric Economic Database Evaluation, IDEAS, reference scanning, targeted author searches and forward citation searching. All databases were searched from inception to March 2015.MethodsWe conducted meta-analyses, simultaneously plotting QoL and health utilisation effects. We conducted subgroup analyses for evidence quality, age, LTC and intervention (setting, target, delivery format, intensity).ResultsNinety-seven studies reporting 114 interventions were included. Thirty-seven studies reported adequate allocation concealment. Fourteen were UK studies. The vast majority of included studies recruited children and young people with asthma (n = 66, 68%). Four per cent of studies evaluated ‘pure’ self-care support (delivered through health technology without additional contact), 23% evaluated facilitated self-care support (≤ 2 hours’/four sessions’ contact), 65% were intensively facilitated (≥ 2 hours’/four sessions’ contact) and 8% were case management (≥ 2 hours’ support with multidisciplinary input). Self-care support was associated with statistically significant, minimal benefits for QoL [effect size (ES) –0.17, 95% confidence interval (CI) –0.23 to –0.11], but lacked clear benefit for hospital admissions (ES –0.05, 95% CI –0.12 to 0.03). This finding endured across intervention intensities and LTCs. Statistically significant, minimal reductions in emergency use were observed (ES –0.11, 95% CI –0.17 to –0.04). The total cost analysis was limited by the small number of data. Subgroup analyses revealed statistically significant, minimal reductions in emergency use for children aged ≤ 13 years (ES –0.10, 95% CI –0.17 to –0.04), children and young people with asthma (ES –0.12, 95% CI –0.18 to –0.06) and children and young people receiving ≥ 2 hours per four sessions of support (ES –0.10, 95% CI –0.17 to –0.03). Preliminary evidence suggested that interventions that include the child or young person, and deliver some content individually, may optimise QoL effects. Face-to-face delivery may help to maximise emergency department effects. Caution is required in interpreting these findings.LimitationsIdentification of optimal models of self-care support is challenged by the size and nature of evidence available. The emphasis on meta-analysis meant that a minority of studies with incomplete but potentially relevant data were excluded.ConclusionsSelf-care support is associated with positive but minimal effects on children and young people’s QoL, and minimal, but potentially important, reductions in emergency use. On current evidence, we cannot reliably conclude that self-care support significantly reduces health-care costs.Future workResearch is needed to explore the short- and longer-term effects of self-care support across a wider range of LTCs.Study registrationThis study is registered as PROSPERO CRD42014015452.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Penny Bee
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Rebecca Pedley
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Amber Rithalia
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | | | - Steven Pryjmachuk
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Susan Kirk
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Peter Bower
- National Institute for Health Research School for Primary Care Research, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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Aragona E, El-Magbri E, Wang J, Scheckelhoff T, Scheckelhoff T, Hyacinthe A, Nair S, Khan A, Nino G, Pillai DK. Impact of Obesity on Clinical Outcomes in Urban Children Hospitalized for Status Asthmaticus. Hosp Pediatr 2016; 6:211-8. [PMID: 27012614 DOI: 10.1542/hpeds.2015-0094] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND AND OBJECTIVE The prevalence of both childhood asthma and obesity remain at historically high levels and disproportionately affect urban children. Asthma is a common and costly cause for pediatric hospitalization. Our objective was to determine the effect of obesity on outcomes among urban children hospitalized with status asthmaticus. METHODS A retrospective cohort study was performed by using billing system data and chart review to evaluate urban children admitted for asthma. Demographics, asthma severity, reported comorbidities, and outcomes were assessed. Obesity was defined by BMI percentile (lean<85%, overweight 85%-95%, obese≥95%). Outcomes were length of stay, hospitalization charges, ICU stay, repeat admissions, and subsequent emergency department (ED) visits. Bivariate analysis assessed for differences between overweight/obese and lean children. Multivariable regression assessed the relationship between overweight status and primary outcomes while controlling for other variables. Post hoc age-stratified analysis was also performed. RESULTS The study included 333 subjects; 38% were overweight/obese. Overweight/obese children admitted with asthma were more likely than lean children to have subsequent ED visits (odds ratio 1.6, 95% confidence interval 1.0-2.6). When stratified by age, overweight/obese preschool-age children (<5 years) were >2 times as likely to have repeat ED visits than lean preschool-age children (odds ratio 2.3, 95% confidence interval 1.0-5.6). There were no differences in the other outcomes between overweight/obese and lean individuals within the entire cohort or within other age groups.
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Affiliation(s)
- Elena Aragona
- Pediatric Hospital Medicine, Tufts Floating Hospital for Children, Boston, Massachusetts;
| | | | | | | | | | | | - Suja Nair
- Pediatric Pulmonology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Amina Khan
- Pediatric Hospital Medicine, Tufts Floating Hospital for Children, Boston, Massachusetts
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Janke AT, Brody AM, Overbeek DL, Bedford JC, Welch RD, Levy PD. Access to care issues and the role of EDs in the wake of the Affordable Care Act. Am J Emerg Med 2014; 33:181-5. [PMID: 25433712 DOI: 10.1016/j.ajem.2014.11.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 11/04/2014] [Accepted: 11/06/2014] [Indexed: 10/24/2022] Open
Abstract
CONTEXT Americans who received public insurance under the Affordable Care Act use the emergency department (ED) more frequently than before they were insured. If newly enrolled patients cannot access primary care and instead rely on the ED, they may not enjoy the full benefits of health care services. OBJECTIVE The objective of the study is to characterize reasons for ED utilization among American adults by insurance status and usual source of care. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional analysis of adult sample respondents to the 2013 National Health Interview Survey reporting 1 or more ED visits in the preceding 12 months. MAIN OUTCOMES AND MEASURES Among American ED users that reported no usual source of care and who reported relying on the ED, 27.7% (95% confidence interval [CI], 23.6%-32.2%) and 35.1% (95% CI, 28.0%-43.0%) noted at least 1 issue of access and none of acuity as a reason for their last ED visit, as compared to 17.7% (95% CI, 16.3%-19.2%) among those with a stable usual source of care. CONCLUSIONS AND RELEVANCE Although past research has shown that those who lack a stable usual source of care use the ED more often, this is the first population-level study to demonstrate their propensity for lack of access-based utilization. In the wake of the Affordable Care Act, EDs will need to evolve into outlets that service a wider range of health care needs rather than function in their current capacity, which is largely to address acute issues in isolation.
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Affiliation(s)
| | - Aaron M Brody
- School of Medicine, Wayne State University, Detroit MI, USA
| | | | | | - Robert D Welch
- Department of Emergency Medicine, Wayne State University, Detroit MI, USA
| | - Phillip D Levy
- Department of Emergency Medicine, Wayne State University, Detroit MI, USA; Cardiovascular Research Institute, Wayne State University, Detroit MI, USA
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Dexheimer JW, Borycki EM, Chiu KW, Johnson KB, Aronsky D. A systematic review of the implementation and impact of asthma protocols. BMC Med Inform Decis Mak 2014; 14:82. [PMID: 25204381 PMCID: PMC4174371 DOI: 10.1186/1472-6947-14-82] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 08/20/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Asthma is one of the most common childhood illnesses. Guideline-driven clinical care positively affects patient outcomes for care. There are several asthma guidelines and reminder methods for implementation to help integrate them into clinical workflow. Our goal is to determine the most prevalent method of guideline implementation; establish which methods significantly improved clinical care; and identify the factors most commonly associated with a successful and sustainable implementation. METHODS PUBMED (MEDLINE), OVID CINAHL, ISI Web of Science, and EMBASE. STUDY SELECTION Studies were included if they evaluated an asthma protocol or prompt, evaluated an intervention, a clinical trial of a protocol implementation, and qualitative studies as part of a protocol intervention. Studies were excluded if they had non-human subjects, were studies on efficacy and effectiveness of drugs, did not include an evaluation component, studied an educational intervention only, or were a case report, survey, editorial, letter to the editor. RESULTS From 14,478 abstracts, we included 101 full-text articles in the analysis. The most frequent study design was pre-post, followed by prospective, population based case series or consecutive case series, and randomized trials. Paper-based reminders were the most frequent with fully computerized, then computer generated, and other modalities. No study reported a decrease in health care practitioner performance or declining patient outcomes. The most common primary outcome measure was compliance with provided or prescribing guidelines, key clinical indicators such as patient outcomes or quality of life, and length of stay. CONCLUSIONS Paper-based implementations are by far the most popular approach to implement a guideline or protocol. The number of publications on asthma protocol reminder systems is increasing. The number of computerized and computer-generated studies is also increasing. Asthma guidelines generally improved patient care and practitioner performance regardless of the implementation method.
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Affiliation(s)
- Judith W Dexheimer
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, MLC 2008, 3333 Burnet Avenue, Cincinnati, OH 45229-3039, USA
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, MLC 2008, 3333 Burnet Avenue, Cincinnati, OH 45229-3039, USA
| | - Elizabeth M Borycki
- School of Health Information Sciences, University of Victoria, PO Box 3050 STN CSC, Victoria, BC V8W 3P5, Canada
| | - Kou-Wei Chiu
- Department of Biomedical Informatics, Vanderbilt University, 400 Eskind Biomedical Library, 2209 Garland Avenue, Nashville, TN 37232, USA
| | - Kevin B Johnson
- Department of Biomedical Informatics, Vanderbilt University, 400 Eskind Biomedical Library, 2209 Garland Avenue, Nashville, TN 37232, USA
| | - Dominik Aronsky
- Department of Biomedical Informatics, Vanderbilt University, 400 Eskind Biomedical Library, 2209 Garland Avenue, Nashville, TN 37232, USA
- Department of Emergency Medicine, Vanderbilt University, 400 Eskind Biomedical Library, 2209 Garland Avenue, Nashville, TN 37232, USA
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Eakin MN, Rand CS, Bilderback A, Bollinger ME, Butz A, Kandasamy V, Riekert KA. Asthma in Head Start children: effects of the Breathmobile program and family communication on asthma outcomes. J Allergy Clin Immunol 2011; 129:664-70. [PMID: 22104603 DOI: 10.1016/j.jaci.2011.10.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Revised: 09/26/2011] [Accepted: 10/05/2011] [Indexed: 12/31/2022]
Abstract
BACKGROUND Asthma morbidity and mortality rates are high among young inner-city children. Lack of routine primary care provider visits, poor access to care, and poor patient-physician communication might be contributing factors. OBJECTIVE This study evaluated the effects of providing Breathmobile services only, a Facilitated Asthma Communication Intervention (FACI) only, or both Breathmobile plus FACI on asthma outcomes relative to standard care. METHODS Children with asthma (n = 322; mean age, 4 years; 53% male; 97% African American) were recruited from Head Start programs in Baltimore City and randomized into 4 groups. Outcome measures included symptom-free days (SFDs), urgent care use (emergency department visits and hospitalizations), and medication use (courses of oral steroids and proportion taking an asthma controller medication), as reported by caregivers at baseline, 6-month, and 12-month assessments. Generalized estimating equations models were conducted to examine the differential treatment effects of the Breathmobile and FACI compared with standard care. RESULTS Children in the combined treatment group (Breathmobile plus FACI) had an increase of 1.7 (6.6%) SFDs that was not maintained at 12 months. In intent-to-treat analyses the FACI-only group had an increase in the number of emergency department visits at 6 months, which was not present at 12 months or in the post hoc as-treated analyses. No significant differences were found between the intervention groups compared with those receiving standard care on all other outcome measures. CONCLUSIONS Other than a slight improvement in SFDs at 6 months in the Breathmobile plus FACI group, the intervention components did not result in any significant improvements in asthma management or asthma morbidity.
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Affiliation(s)
- Michelle N Eakin
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21224, USA
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