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Girardi P, Rigoni S, Ferrante D, Silvestri S, Angelini A, Cuccaro F, Oddone E, Vicentini M, Barone-Adesi F, Tunesi S, Migliore E, Roncaglia F, Sala O, Pirastu R, Chellini E, Miligi L, Perticaroli P, Bressan V, Merler E, Azzolina D, Marinaccio A, Massari S, Magnani C. Asbestos exposure and asbestosis mortality in Italian cement-asbestos cohorts: Dose-response relationship and the role of competing death causes. Am J Ind Med 2024; 67:813-822. [PMID: 38943482 DOI: 10.1002/ajim.23629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 04/17/2024] [Accepted: 06/09/2024] [Indexed: 07/01/2024]
Abstract
OBJECTIVES In Italy, asbestos was used intensively until its ban in 1992, which was extended for asbestos cement factories until 1994. The aim of this study was to evaluate the dose-response between asbestos exposure and asbestosis mortality across a pool of Italian occupational cohorts, taking into account the presence of competing risks. METHODS Cohorts were followed for vital status and the cause of death was ascertained by a linkage with mortality registers. Cause-specific (CS) Cox-regression models were used to evaluate the dose-exposure relationship between asbestosis mortality and the time-dependent cumulative exposure index (CEI) to asbestos. Fine and Gray regression models were computed to assess the effect of competing risks of death. RESULTS The cohort included 12,963 asbestos cement workers. During the follow-up period (1960-2012), of a total of 6961 deaths, we observed 416 deaths attributed to asbestosis, 879 to lung cancer, 400 to primary pleural cancer, 135 to peritoneal cancer, and 1825 to diseases of the circulatory system. The CS model showed a strong association between CEI and asbestosis mortality. Dose-response models estimated an increasing trend in mortality even below a CEI of 25 ff/mL-years. Lung cancer and circulatory diseases were the main competing causes of death. CONCLUSIONS Asbestos exposure among Italian asbestos-cement workers has led to a very high number of deaths from asbestosis and asbestos-related diseases. The increasing risk trend associated with excess deaths, even at low exposure levels, suggests that the proposed limit values would not have been adequate to prevent disability and mortality from asbestosis.
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Affiliation(s)
- Paolo Girardi
- Department of Environmental Sciences, Informatics and Statistics, Ca' Foscari University of Venice, Venezia, Italy
| | - Sara Rigoni
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | - Daniela Ferrante
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | - Stefano Silvestri
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | - Alessia Angelini
- Institute for the Study, Prevention and Oncology Network (ISPRO), Firenze, Italy
| | - Francesco Cuccaro
- Epidemiology and Statistics Unit, Local Health Unit of Barletta-Andria-Trani, Barletta, Italy
| | - Enrico Oddone
- Department of Public Health and Experimental and Forensic Medicine, University of Pavia, Italy
- Hospital Occupational Medicine Unit, ICS Maugeri IRCCS, Pavia, Italy
| | - Massimo Vicentini
- Epidemiology Unit, Local Health Authority-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | | | - Sara Tunesi
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | - Enrica Migliore
- Cancer Epidemiology Unit, AOU Città della Salute e della Scienza di Torino, CPO Piedmont and University of Turin, Torino, Italy
| | - Francesca Roncaglia
- Epidemiology Unit, Local Health Authority-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Orietta Sala
- (former) Regional Asbestos Laboratory ARPAE Emilia-Romagna, Reggio Emilia, Italy
| | - Roberta Pirastu
- (former) "Charles Darwin" Department of Biology and Biotechnology, La Sapienza University, Roma, Italy
| | - Elisabetta Chellini
- (former) Institute for the Study, Prevention and Oncology Network (ISPRO), Firenze, Italy
| | - Lucia Miligi
- Institute for the Study, Prevention and Oncology Network (ISPRO), Firenze, Italy
| | | | | | - Enzo Merler
- (former) Veneto Register of Mesothelioma cases, Regional Epidemiological System, AULSS 6, Padova, Italy
| | - Danila Azzolina
- Department of Environmental Sciences and Prevention, University of Ferrara, Ferrara, Italy
| | - Alessandro Marinaccio
- Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Unit of Occupational and Environmental Epidemiology, Italian Mesothelioma Register, Italian Workers' Compensation Authority (INAIL), Roma, Italy
| | - Stefania Massari
- Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Unit of Occupational and Environmental Epidemiology, Italian Mesothelioma Register, Italian Workers' Compensation Authority (INAIL), Roma, Italy
| | - Corrado Magnani
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
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Belackova L, Verbeek JH, Hoving JL, van der Molen HF, Gagliardi D, Curti S, Hulshof CT, Scheepers PT. Personal protective equipment for preventing asbestos exposure in workers. Cochrane Database Syst Rev 2024; 5:CD015158. [PMID: 38695617 PMCID: PMC11064758 DOI: 10.1002/14651858.cd015158.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
BACKGROUND Asbestos exposure can lead to asbestos-related diseases. The European Union (EU) has adopted regulations for workplaces where asbestos is present. The EU occupational exposure limit (OEL) for asbestos is 0.1 fibres per cubic centimetre of air (f/cm3) as an eight-hour average. Different types of personal protective equipment (PPE) are available to provide protection and minimise exposure; however, their effectiveness is unclear. OBJECTIVES To assess the effects of personal protective equipment (PPE), including donning and doffing procedures and individual hygienic behaviour, compared to no availability and use of such equipment or alternative equipment, on asbestos exposure in workers in asbestos demolition and repair work. SEARCH METHODS We searched MEDLINE, Embase, CENTRAL, and Scopus (September 2022), and we checked the reference lists of included studies. SELECTION CRITERIA We included studies that measured asbestos concentration outside and inside PPE (considering outside concentration a surrogate for no PPE), exposure to asbestos after doffing PPE, donning and doffing errors, nonadherence to regulations, and adverse effects of PPE. DATA COLLECTION AND ANALYSIS Two review authors selected studies, extracted data, and assessed risk of bias using ROBINS-I. We categorised PPE as full-face filtering masks, supplied air respirators (SARs), and powered air-purifying respirators (PAPRs). Values for asbestos outside and inside PPE were transformed to logarithmic values for random-effects meta-analysis. Pooled logarithmic mean differences (MDs) were exponentiated to obtain the ratio of means (RoM) and 95% confidence interval (95% CI). The RoM shows the degree of protection provided by the respirators (workplace protection factor). Since the RoM is likely to be much higher at higher outside concentrations, we presented separate results according to the outside asbestos concentration, as follows. • Below 0.01 f/cm3 (band 1) • 0.01 f/cm3 to below 0.1 f/cm3 (band 2) • 0.1 f/cm3 to below 1 f/cm3 (band 3) • 1 f/cm3 to below 10 f/cm3 (band 4) • 10 f/cm3 to below 100 f/cm3 (band 5) • 100 f/cm3 to below 1000 f/cm3 (band 6) Additionally, we determined whether the inside concentrations per respirator and concentration band complied with the current EU OEL (0.1 f/cm3) and proposed EU OEL (0.01 f/cm3). MAIN RESULTS We identified six studies that measured asbestos concentrations outside and inside respiratory protective equipment (RPE) and one cross-over study that compared the effect of two different coveralls on body temperature. No studies evaluated the remaining predefined outcomes. Most studies were at overall moderate risk of bias due to insufficient reporting. The cross-over study was at high risk of bias. Full-face filtering masks Two studies evaluated full-face filtering masks. They provided insufficient data for band 1 and band 6. The results for the remaining bands were as follows. • Band 2: RoM 19 (95% CI 17.6 to 20.1; 1 study, 3 measurements; moderate certainty) • Band 3: RoM 69 (95% CI 26.6 to 175.9; 2 studies, 17 measurements; very low certainty) • Band 4: RoM 455 (95% CI 270.4 to 765.1; 1 study, 16 measurements; low certainty) • Band 5: RoM 2752 (95% CI 1236.5 to 6063.2;1 study, 3 measurements; low certainty) The inside measurements in band 5 did not comply with the EU OEL of 0.1 f/cm3, and no inside measurements complied with the proposed EU OEL of 0.01 f/cm3. Supplied air respirators Two studies evaluated supplied air respirators. They provided no data for band 6. The results for the remaining bands were as follows. • Band 1: RoM 11 (95% CI 7.6 to 14.9; 1 study, 134 measurements; moderate certainty) • Band 2: RoM 63 (95% CI 43.8 to 90.9; 1 study, 17 measurements; moderate certainty) • Band 3: RoM 528 (95% CI 368.7 to 757.5; 1 study, 38 measurements; moderate certainty) • Band 4: RoM 4638 (95% CI 3071.7 to 7044.5; 1 study, 49 measurements; moderate certainty) • Band 5: RoM 26,134 (16,647.2 to 41,357.1; 1 study, 22 measurements; moderate certainty) All inside measurements complied with the current OEL of 0.1 f/cm3 and the proposed OEL of 0.01 f/cm3. Powered air-purifying respirators Three studies evaluated PAPRs. The results per band were as follows. • Band 1: RoM 8 (95% CI 3.7 to 19.1; 1 study, 23 measurements; moderate certainty) • Band 2: RoM 90 (95% CI 64.7 to 126.5; 1 study, 17 measurements; moderate certainty) • Band 3: RoM 104 (95% CI 23.1 to 464.1; 3 studies, 14 measurements; very low certainty) • Band 4: RoM 706 (95% CI 219.2 to 2253.0; 2 studies, 43 measurements; very low certainty) • Band 5: RoM 1366 (544.6 to 3428.9; 2 studies, 8 measurements; low certainty) • Band 6: RoM 18,958 (95% CI 4023.9 to 90,219.4; 2 studies, 13 measurements; very low certainty) All inside measurements complied with the 0.1 f/cm3 OEL when the outside concentration was below 10 f/cm3 (band 1 to band 4). From band 3, no measurements complied with the proposed OEL of 0.01 f/cm3. Different types of coveralls One study reported the adverse effects of coveralls. A polyethylene suit may increase the body temperature more than a ventilated impermeable polyvinyl (PVC) coverall, but the evidence is very uncertain (MD 0.17 °C, 95% CI -0.08 to 0.42; 1 study, 11 participants; very low certainty). AUTHORS' CONCLUSIONS Where the outside asbestos concentration is below 0.1 f/cm3, SARS and PAPRs likely reduce exposure to below the proposed OEL of 0.01 f/cm3. For outside concentrations up to 10 f/cm3, all respirators may reduce exposure below the current OEL, but only SAR also below the proposed OEL. In band 5 (10 to < 100 f/cm3), full-face filtering masks may not reduce asbestos exposure below either OEL, SARs likely reduce exposure below both OELs, and there were no data for PAPRs. In band 6 (100 f/cm3 to < 1000 f/cm3), PAPRs may not reduce exposure below either OEL, and there were no data for full-face filtering masks or SARs. Some coveralls may increase body temperature more than others. Randomised studies are needed to directly compare PAPRs and SARs at higher asbestos concentrations and to assess adverse effects. Future studies should assess the effects of doffing procedures.
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Affiliation(s)
- Lea Belackova
- Cochrane Work, Coronel Institute of Occupational Health, Amsterdam UMC, Amsterdam, Netherlands
| | - Jos H Verbeek
- Cochrane Work, Coronel Institute of Occupational Health, Amsterdam UMC, Amsterdam, Netherlands
| | - Jan L Hoving
- Cochrane Work, Coronel Institute of Occupational Health, Amsterdam UMC, Amsterdam, Netherlands
- Public and Occupational Health, University Medical Centers Amsterdam, Amsterdam, Netherlands
| | - Henk F van der Molen
- Public and Occupational Health, Amsterdam UMC, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Diana Gagliardi
- Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, INAIL, Rome, Italy
| | - Stefania Curti
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Carel Tj Hulshof
- Netherlands Society of Occupational Medicine (NVAB), Centre of Excellence, Utrecht, Netherlands
| | - Paul Tj Scheepers
- Radboud Institute for Health Sciences, Radboudumc, Nijmegen, Netherlands
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Azzolina D, Consonni D, Ferrante D, Mirabelli D, Silvestri S, Luberto F, Angelini A, Cuccaro F, Nannavecchia AM, Oddone E, Vicentini M, Barone-Adesi F, Cena T, Mangone L, Roncaglia F, Sala O, Menegozzo S, Pirastu R, Tunesi S, Chellini E, Miligi L, Perticaroli P, Pettinari A, Bressan V, Merler E, Girardi P, Bisceglia L, Marinaccio A, Massari S, Magnani C. Rate advancement measurement for lung cancer and pleural mesothelioma in asbestos-exposed workers. Thorax 2023; 78:808-815. [PMID: 36357176 DOI: 10.1136/thorax-2021-217862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 10/13/2022] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Exposure to asbestos increases the risk of lung cancer and mesothelioma. Few studies quantified the premature occurrence of these diseases in asbestos-exposed workers. Focus on premature disease onset (rate advancement or acceleration) can be useful in risk communication and for the evaluation of exposure impact. We estimated rate advancement for total mortality, lung cancer and pleural mesothelioma deaths, by classes of cumulative asbestos exposure in a pooled cohort of asbestos cement (AC) workers in Italy. METHOD The cohort study included 12 578 workers from 21 cohorts, with 6626 deaths in total, 858 deaths from lung cancer and 394 from pleural malignant neoplasm (MN). Rate advancement was estimated by fitting a competitive mortality Weibull model to the hazard of death over time since first exposure (TSFE). RESULT Acceleration time (AT) was estimated at different TSFE values. The highest level of cumulative exposure compared with the lowest, for pleural MN AT was 16.9 (95% CI 14.9 to 19.2) and 33.8 (95% CI 29.8 to 38.4) years at TSFE of 20 and 40 years, respectively. For lung cancer, it was 13.3 (95% CI 12.0 to 14.7) and 26.6 (95% CI 23.9 to 29.4) years, respectively. As for total mortality, AT was 3.35 (95% CI 2.98 to 3.71) years at 20 years TSFE, and 6.70 (95% CI 5.95 to 7.41) at 40 years TSFE. CONCLUSION The current study observed marked rate advancement after asbestos exposure for lung cancer and pleural mesothelioma, as well as for total mortality.
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Affiliation(s)
| | - Dario Consonni
- Unit of Epidemiology, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniela Ferrante
- Department of Translational Medicine, Unit of Medical Statistics and Cancer Epidemiology, Università degli Studi del Piemonte Orientale Amedeo Avogadro, Novara, Italy
| | - Dario Mirabelli
- Unit of Cancer Epidemiology, CPO Piedmont and University of Turin, Turin, Italy
| | - Stefano Silvestri
- Department of Translational Medicine, Unit of Medical Statistics and Cancer Epidemiology, Università degli Studi del Piemonte Orientale Amedeo Avogadro, Novara, Italy
| | - Ferdinando Luberto
- Epidemiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Alessia Angelini
- Department of Translational Medicine, Unit of Medical Statistics and Cancer Epidemiology, Università degli Studi del Piemonte Orientale Amedeo Avogadro, Novara, Italy
| | - Francesco Cuccaro
- Unit of Epidemiology and Statistics, Local Health Unit of Barletta-Andria-Trani, Barletta, Italy
| | - Anna Maria Nannavecchia
- Unit of Epidemiology and Statistics, Local Health Unit of Barletta-Andria-Trani, Barletta, Italy
| | - Enrico Oddone
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, and ICS Maugeri IRCCS, Pavia, Italy
| | - Massimo Vicentini
- Epidemiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Francesco Barone-Adesi
- Unit of Public Health, Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | - Tiziana Cena
- Department of Translational Medicine, Unit of Medical Statistics and Cancer Epidemiology, Università degli Studi del Piemonte Orientale Amedeo Avogadro, Novara, Italy
| | - Lucia Mangone
- Epidemiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Francesca Roncaglia
- Epidemiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Orietta Sala
- Regional Agency for Protection, Environment and Energy Emilia-Romagna, Reggio Emilia, Italy
| | - Simona Menegozzo
- National Cancer Institute IRCCS Fondazione Pascale, Napoli, Italy
| | - Roberta Pirastu
- Department of Biology and Biotechnologies 'Charles Darwin', Sapienza University, Rome, Italy
| | - Sara Tunesi
- Department of Translational Medicine, Unit of Medical Statistics and Cancer Epidemiology, Università degli Studi del Piemonte Orientale Amedeo Avogadro, Novara, Italy
| | - Elisabetta Chellini
- Occupational & Environmental Epidemiology Unit-Institute for Cancer Research, Prevention and Clinical Network (ISPRO), Firenze, Italy
| | - Lucia Miligi
- Occupational & Environmental Epidemiology Unit-Institute for Cancer Research, Prevention and Clinical Network (ISPRO), Firenze, Italy
| | | | | | | | - Enzo Merler
- Mesothelioma Register of the Veneto Region, Regional Epidemiologic System, Local Health Unit 6, Padua, Italy
| | - Paolo Girardi
- Mesothelioma Register of the Veneto Region, Regional Epidemiologic System, Local Health Unit 6, Padua, Italy
- Department of Developmental and Social Psychology Department of Statistical Sciences University of Padova, Padua, Italy
| | - Lucia Bisceglia
- Apulia Regional Agency for Health and Social Policies-ARESS Puglia, Bari, Italy
| | - Alessandro Marinaccio
- Italian Workers' Compensation Authority (INAIL), Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Unit of Occupational and Environmental Epidemiology, Italian Mesothelioma Register, Roma, Italy
| | - Stefania Massari
- Italian Workers' Compensation Authority (INAIL), Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Unit of Occupational and Environmental Epidemiology, Italian Mesothelioma Register, Roma, Italy
| | - Corrado Magnani
- Department of Translational Medicine, Unit of Medical Statistics and Cancer Epidemiology, Università degli Studi del Piemonte Orientale Amedeo Avogadro, Novara, Italy
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Verbeek JH, Hoving JL, Molen HF, Gagliardi D, Curti S, Hulshof CTJ, Scheepers PTJ, Marinaccio A, Belackova L. Personal protective equipment for preventing asbestos exposure in workers. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2022. [PMCID: PMC9595100 DOI: 10.1002/14651858.cd015158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the effects of personal protective equipment, including donning and doffing procedures and individual hygienic behaviour, compared to no such equipment or alternative equipment, on asbestos exposure in workers exposed to asbestos in demolition and repair work.
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Affiliation(s)
| | - Jos H Verbeek
- Cochrane Work, Coronel Institute of Occupational HealthAmsterdam UMCAmsterdamNetherlands
| | - Jan L Hoving
- Cochrane Work, Coronel Institute of Occupational HealthAmsterdam UMCAmsterdamNetherlands
| | - Henk F Molen
- Coronel Institute of Occupational HealthAmsterdam UMCAmsterdamNetherlands
| | - Diana Gagliardi
- Department of Occupational and Environmental Medicine, Epidemiology and HygieneINAILRomeItaly
| | - Stefania Curti
- Department of Medical and Surgical SciencesUniversity of BolognaBolognaItaly
| | - Carel TJ Hulshof
- Netherlands Society of Occupational Medicine (NVAB)Centre of ExcellenceUtrechtNetherlands
| | | | - Alessandro Marinaccio
- Department of Occupational and Environmental Medicine, Epidemiology and HygieneINAILRomeItaly
| | - Lea Belackova
- Cochrane Work, Coronel Institute of Occupational HealthAmsterdam UMCAmsterdamNetherlands
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Belackova L, Verbeek JH, Hoving JL, van der Molen HF, Gagliardi D, Curti S, Hulshof CTJ, Scheepers PTJ, Marinaccio A. Legal banning of asbestos for preventing asbestos exposure. Hippokratia 2022. [DOI: 10.1002/14651858.cd015106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Lea Belackova
- Cochrane Work, Coronel Institute of Occupational Health; Amsterdam UMC ; Amsterdam Netherlands
| | - Jos H Verbeek
- Cochrane Work, Coronel Institute of Occupational Health; Amsterdam UMC ; Amsterdam Netherlands
| | - Jan L Hoving
- Cochrane Work, Coronel Institute of Occupational Health; Amsterdam UMC ; Amsterdam Netherlands
| | | | - Diana Gagliardi
- Department of Occupational and Environmental Medicine, Epidemiology and Hygiene; INAIL; Rome Italy
| | - Stefania Curti
- Department of Medical and Surgical Sciences; University of Bologna; Bologna Italy
| | - Carel TJ Hulshof
- Netherlands Society of Occupational Medicine (NVAB); Centre of Excellence; Utrecht Netherlands
| | - Paul TJ Scheepers
- Radboud Institute for Health Sciences; Radboudumc; Nijmegen Netherlands
- Healt Evidence; Radboudumc; NIjmegen Netherlands
| | - Alessandro Marinaccio
- Department of Occupational and Environmental Medicine, Epidemiology and Hygiene; INAIL; Rome Italy
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