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Tan F, Chen S, Huang L, Chen Y, Wu Y. Continuous palliative sedation in terminally ill patients with cancer: a retrospective observational cohort study from a Chinese palliative care unit. BMJ Open 2023; 13:e071859. [PMID: 37230518 DOI: 10.1136/bmjopen-2023-071859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
OBJECTIVE This study aimed to describe a 4-year practice of continuous palliative sedation (CPS) in a palliative medicine ward of an academic hospital in China. To compare the survival time of patients with cancer with and without CPS during end-of-life care, we used the propensity score matching method and explored potential patient-related factors. DESIGN A retrospective observational cohort study. SETTING The palliative ward at a tertiary teaching hospital between January 2018 and 10 May 2022, in Chengdu, Sichuan, China. PARTICIPANTS The palliative care unit had 1445 deaths. We excluded 283 patients who were sedated on admission due to mechanical ventilation or non-invasive ventilators, 122 patients who were sedated due to epilepsy and sleep disorders, 69 patients without cancer, 26 patients who were younger than 18 years, 435 patients with end-of-life intervention when the patients' vital signs were unstable and 5 patients with unavailable medical records. Finally, we included 505 patients with cancer who met our requirements. MAIN OUTCOME MEASURES The survival time and analysis of sedation potential factors between the two groups were compared. RESULTS The total prevalence of CPS was 39.7%. Patients who were sedated more commonly experienced delirium, dyspnoea, refractory existential or psychological distress, and pain. After propensity score matching, the median survival was 10 (IQR: 5-17.75) and 9 days (IQR: 4-16) with and without CPS, respectively. After matching, the two survival curves of the sedated and non-sedated groups were no different (HR 0.82; 95% CI 0.64 to 0.84; log-rank p=0.10). CONCLUSIONS Developing countries also practise palliative sedation. Median survival was not different between patients who were and were not sedated.
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Affiliation(s)
- Fang Tan
- Department of Palliative Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Shan Chen
- Department of Palliative Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lan Huang
- Department of Palliative Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yang Chen
- Department of Palliative Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yan Wu
- Department of Palliative Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
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Dufort-Rouleau C, Martin B, Barré V, Bédard V, Rouleau ÉD, Beauchesne MF, Quenneville J, Berteau M. Conformity in Prescription and Administration of Respiratory Distress Protocols in a Tertiary Care Hospital in the Province of Quebec: RELIEVE Study. J Palliat Care 2019; 35:21-28. [PMID: 30898064 DOI: 10.1177/0825859719835555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Respiratory distress protocols (RDPs) are protocolized prescriptions comprised of 3 medications (a benzodiazepine, an opioid, and an anticholinergic) administered simultaneously as an emergency treatment for respiratory distress in palliative care patients in the province of Quebec, Canada. However, data on appropriate use that justifies the combination of all 3 components is scarce and based on individual pharmacodynamic properties along with expert consensus. OBJECTIVES Our study aimed to evaluate the conformity and the effectiveness of RDPs prescribed and administered to hospitalized adult patients. METHODS This was a prospective and descriptive study conducted in a single center. Prescription and administration conformity were assessed based on predefined appropriateness criteria. RESULTS A total of 467 adult patients were prescribed a RDP, 175 administrations were documented, and 78 patients received at least 1 RDP. Prescription conformity was assessed on 1473 separate occasions over the trial period. Overall prescription conformity was found to be 37% (95% confidence interval [CI]: 33.6-40.4), and administration conformity was 37.7% (95% CI: 26.2-50.7). Low administration conformity was primarily explained by incorrect indications for RDP use. Seemingly important determinants of higher conformity were prescriber's speciality in palliative care, use of preprinted orders, pharmacist involvement, and hospitalization in the palliative care unit. CONCLUSION This study highlights important gaps in the use of RDPs in our institution. Health-care provider training appears necessary in order to ensure adequate conformity and allow for further evaluation of RDP effectiveness.
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Affiliation(s)
- Camille Dufort-Rouleau
- Department of Pharmacy, Centre intégré universitaire de santé et de services sociaux de l'Estrie-Centre hospitalier universitaire de Sherbrooke, Installations Hôtel-Dieu et Fleurimont, Sherbrooke, Quebec, Canada.,Faculté de pharmacie, Université de Montréal, Montreal, Quebec, Canada
| | - Benjamin Martin
- Department of Pharmacy, Centre intégré universitaire de santé et de services sociaux de l'Estrie-Centre hospitalier universitaire de Sherbrooke, Installations Hôtel-Dieu et Fleurimont, Sherbrooke, Quebec, Canada.,Faculté de pharmacie, Université de Montréal, Montreal, Quebec, Canada.,Centre intégré de santé et de services sociaux de Lanaudière - Centre hospitalier Pierre-Le Gardeur, Terrebonne, Quebec, Canada
| | - Vincent Barré
- Department of Pharmacy, Centre intégré universitaire de santé et de services sociaux de l'Estrie-Centre hospitalier universitaire de Sherbrooke, Installations Hôtel-Dieu et Fleurimont, Sherbrooke, Quebec, Canada.,Faculté de pharmacie, Université de Montréal, Montreal, Quebec, Canada.,Centre intégré universitaire de santé et de services sociaux de l'Estrie-Centre hospitalier universitaire de Sherbrooke, Installation Hôpital de Granby, Granby, Quebec, Canada
| | - Véronique Bédard
- Department of Pharmacy, Centre intégré universitaire de santé et de services sociaux de l'Estrie-Centre hospitalier universitaire de Sherbrooke, Installations Hôtel-Dieu et Fleurimont, Sherbrooke, Quebec, Canada.,Faculté de pharmacie, Université de Montréal, Montreal, Quebec, Canada.,Centre intégré universitaire de santé et de services sociaux de l'Estrie-Centre hospitalier universitaire de Sherbrooke, Installation Hôpital d'Asbestos, Asbestos, Quebec, Canada
| | - Émilie Dufort Rouleau
- Department of Pharmacy, Centre intégré universitaire de santé et de services sociaux de l'Estrie-Centre hospitalier universitaire de Sherbrooke, Installations Hôtel-Dieu et Fleurimont, Sherbrooke, Quebec, Canada
| | - Marie-France Beauchesne
- Department of Pharmacy, Centre intégré universitaire de santé et de services sociaux de l'Estrie-Centre hospitalier universitaire de Sherbrooke, Installations Hôtel-Dieu et Fleurimont, Sherbrooke, Quebec, Canada.,Faculté de pharmacie, Université de Montréal, Montreal, Quebec, Canada.,Centre de recherche du Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Julie Quenneville
- Department of Pharmacy, Centre intégré universitaire de santé et de services sociaux de l'Estrie-Centre hospitalier universitaire de Sherbrooke, Installations Hôtel-Dieu et Fleurimont, Sherbrooke, Quebec, Canada
| | - Mathieu Berteau
- Department of Pharmacy, Centre intégré universitaire de santé et de services sociaux de l'Estrie-Centre hospitalier universitaire de Sherbrooke, Installations Hôtel-Dieu et Fleurimont, Sherbrooke, Quebec, Canada
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Cherny N. ESMO Clinical Practice Guidelines for the management of refractory symptoms at the end of life and the use of palliative sedation. Ann Oncol 2014; 25 Suppl 3:iii143-52. [DOI: 10.1093/annonc/mdu238] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Cherny NI. Palliative sedation for the relief of refractory physical symptoms. PROGRESS IN PALLIATIVE CARE 2013. [DOI: 10.1179/096992608x291234] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Kumar SP, Jim A. Physical therapy in palliative care: from symptom control to quality of life: a critical review. Indian J Palliat Care 2011; 16:138-46. [PMID: 21218003 PMCID: PMC3012236 DOI: 10.4103/0973-1075.73670] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Physiotherapy is concerned with identifying and maximizing movement potential, within the spheres of promotion, prevention, treatment and rehabilitation. Physical therapists practice in a broad range of inpatient, outpatient, and community-based settings such as hospice and palliative care centers where as part of a multidisciplinary team of care, they address the physical and functional dimensions of the patients’ suffering. Physiotherapy treatment methods like therapeutic exercise, electrical modalities, thermal modalities, actinotherapy, mechanical modalities, manual physical therapy and assistive devices are useful for a range of life-threatening and life-limiting conditions like cancer and cancer-associated conditions; HIV; neurodegenerative disorders like amyotrophic lateral sclerosis, multiple sclerosis; respiratory disorders like idiopathic pulmonary fibrosis; and altered mental states. The professional armamentarium is still expanding with inclusion of other miscellaneous techniques which were also proven to be effective in improving quality of life in these patients. Considering the scope of physiotherapy in India, and in palliative care, professionals in a multidisciplinary palliative care team need to understand and mutually involve toward policy changes to successfully implement physical therapeutic palliative care delivery.
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Affiliation(s)
- Senthil P Kumar
- Department of Physiotherapy, Kasturba Medical College, Manipal University, Mangalore, India
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Clemens KE, Klaschik E. Dyspnoea associated with anxiety—symptomatic therapy with opioids in combination with lorazepam and its effect on ventilation in palliative care patients. Support Care Cancer 2010; 19:2027-33. [DOI: 10.1007/s00520-010-1058-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Accepted: 11/25/2010] [Indexed: 11/29/2022]
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Abstract
Oncology care has changed markedly in the past decade. With new therapies, patients are experienced in living with life-threatening illness and believe in the abilities of science and the health care system to find new therapies. Changes in the treatment paradigm have altered oncology nursing practice. The integration of newer targeted therapies with their specific side-effect profiles also has changed end-of-life care. Strategies used to manage patients during the active treatment phase of illness can inform and improve nursing practice when active care has been set aside. Evidence-based practice provides a guide to identify, critically appraise, and use evidence to solve clinical problems.
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Hallenbeck J, Kauser F, LeGrand SB. Theophylline for Unexplained Dyspnea in Palliative Medicine: A Case Report. J Palliat Med 2008; 11:510-3. [DOI: 10.1089/jpm.2008.9950] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Fariha Kauser
- The Section of Palliative Medicine and Supportive Care, The Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio
| | - Susan B. LeGrand
- The Section of Palliative Medicine and Supportive Care, The Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio
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Gupta D, Lis CG, Grutsch JF. The relationship between dyspnea and patient satisfaction with quality of life in advanced cancer. Support Care Cancer 2006; 15:533-8. [PMID: 17120067 DOI: 10.1007/s00520-006-0178-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2006] [Accepted: 10/04/2006] [Indexed: 11/12/2022]
Abstract
GOALS OF THE WORK Dyspnea is a common symptom in patients with advanced cancer. The goal of this study was to investigate the relationship between dyspnea and patient satisfaction with quality of life (QoL) in advanced cancer. MATERIALS AND METHODS A case series of 954 cancer patients treated at the Cancer Treatment Centers of America was investigated. Dyspnea was measured using the EORTC dyspnea subscale. Patient satisfaction with QoL was measured using the Ferrans and Powers Quality of Life Index (QLI). The relationship between dyspnea and QLI was evaluated using multivariate analysis of variance and multiple regression analysis. RESULTS Of 954 patients, 579 were females and 375 males with the median age at presentation of 56 years (range: 20-90 years). Of these patients, 66% did not respond to prior treatment. Most common cancers were breast (26%), colorectal (19%) and lung (16%). After controlling for the effects of age and treatment history, every ten unit increase in dyspnea was statistically significantly associated with 0.81, 0.16, 0.47, and 0.47 unit decline in QLI health/physical, social/economic, psychological/spiritual and global function score, respectively. CONCLUSIONS We found that dyspnea is strongly correlated with patient satisfaction with QoL in advanced cancer. Future studies should evaluate the impact of integrative cancer care services on patient satisfaction with QoL.
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Affiliation(s)
- Digant Gupta
- Office of Research, Cancer Treatment Centers of America, Midwestern Regional Medical Center, Zion, IL 60099, USA.
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Cherny NI. Sedation for the care of patients with advanced cancer. ACTA ACUST UNITED AC 2006; 3:492-500. [PMID: 16955088 DOI: 10.1038/ncponc0583] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2006] [Accepted: 05/02/2006] [Indexed: 11/09/2022]
Abstract
Sedation in the context of palliative medicine is the monitored use of medications to induce varying degrees of unconsciousness to bring about a state of decreased or absent awareness (i.e. unconsciousness) in order to relieve the burden of otherwise intractable suffering. Sedation is used in palliative care in several settings: transient controlled sedation, sedation in the management of refractory symptoms at the end of life, emergency sedation, respite sedation, and sedation for refractory psychological or existential suffering. Sedation is controversial in that it diminishes the capacity of the patient to interact, function, and, in some cases, live. There is no distinct ethical problem in the use of sedation to relieve otherwise intolerable suffering in patients who are dying. Since all medical treatments involve risks and benefits, each potential option must be evaluated for its promise with regards to achieving the goals of care. When risks of treatment are involved, to be justified these risks must be proportionate to the gravity of the clinical indication. Some aspects of management, such as the need for hydration in patients undergoing sedation and the use of sedation in the management of psychological and spiritual suffering, remain controversial.
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Affiliation(s)
- Nathan I Cherny
- Department of Medical Oncology, Shaare Zedek Medical Center, PO Box 3235, Jerusalem 91031, Israel.
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Abstract
Dyspnea is a common symptom at the end of life. It occurs as the result of a complex mix of physical, biochemical, and perceptual components. When patients and their healthcare providers focus on the "numbers" related to oxygenation, rather than comfort, the individual's quality of life can suffer.
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Navigante AH, Cerchietti LCA, Castro MA, Lutteral MA, Cabalar ME. Midazolam as adjunct therapy to morphine in the alleviation of severe dyspnea perception in patients with advanced cancer. J Pain Symptom Manage 2006; 31:38-47. [PMID: 16442481 DOI: 10.1016/j.jpainsymman.2005.06.009] [Citation(s) in RCA: 161] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2005] [Indexed: 01/17/2023]
Abstract
The mainstay of dyspnea palliation remains altering its central perception. Morphine is the main drug and anxiolytics have a less established role. This trial assessed the role of midazolam as adjunct therapy to morphine in the alleviation of severe dyspnea perception in terminally ill cancer patients. One hundred and one patients with severe dyspnea were randomized to receive around-the-clock morphine (2.5 mg every 4 hours for opioid-naïve patients or a 25% increment over the daily dose for those receiving baseline opioids) with midazolam rescue doses (5 mg) in case of breakthrough dyspnea (BD) (Group Mo); around-the-clock midazolam (5 mg every 4 hours) with morphine rescues (2.5 mg) in case of BD (Group Mi); or around-the-clock morphine (2.5 mg every 4 hours for opioid-naïve patients or a 25% increment over the daily dose for those receiving baseline opioids) plus midazolam (5 mg every 4 hours) with morphine rescue doses (2.5 mg) in case of BD (Group MM). All drugs were given subcutaneously in a single-blinded way. Thirty-five patients were entered in Group Mo, 33 entered in Mi, and 33 entered in MM. At 24 hours, patients who experienced dyspnea relief were 69%, 46%, and 92% in the Mo, Mi, and MM groups, respectively (P = 0.0004 and P = 0.03 for MM vs. Mi and MM vs. Mo, respectively). At 48 hours, those with no dyspnea relief (no controlled dyspnea) were 12.5%, 26%, and 4% for the Mo, Mi, and MM groups, respectively (P = 0.04 for MM vs. Mi). During the first day, patients with BD for the groups Mo, Mi, and MM were 34.3%, 36.4%, and 21.2%, respectively (P = NS or not significant), whereas during the second day, these percentages were 38%, 38.5%, and 24%, respectively (P = NS). The data demonstrate that the beneficial effects of morphine in controlling baseline levels of dyspnea could be improved with the addition of midazolam to the treatment.
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Affiliation(s)
- Alfredo H Navigante
- Internal Medicine Department and Translational Research Unit, Angel H. Roffo Cancer Institute, University of Buenos Aires, Buenos Aires, Argentina
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Abstract
OBJECTIVES To discuss the evidence-based practice process for palliative care, from defining a clinical problem to implementation and evaluation of an evidence-based practice change. DATA SOURCES Professional experience, literature, practice guidelines, and web sites related to evidence-based practice and palliative care. CONCLUSION Nurses caring for patients needing palliative care need evidence from multiple sources. Using a systematic process to find and appraise evidence followed by strategically planning for implementation and evaluation of evidence-based practice changes optimizes the likelihood of enhanced patient care. IMPLICATIONS FOR NURSING PRACTICE The integration of evidence-based practices into palliative care nursing will empower nurses to promote optimal patient outcomes and decrease practice variability.
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Ahmedzai SH, Laude E, Robertson A, Troy G, Vora V. A double-blind, randomised, controlled Phase II trial of Heliox28 gas mixture in lung cancer patients with dyspnoea on exertion. Br J Cancer 2004; 90:366-71. [PMID: 14735178 PMCID: PMC2409543 DOI: 10.1038/sj.bjc.6601527] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Helium has a low density and the potential of reducing the work of breathing and improving alveolar ventilation when replacing nitrogen in air. A Phase II, double-blind, randomised, prospective, controlled trial was undertaken to assess whether Heliox28 (72% He/28% O2) compared with oxygen-enriched air (72% N2/28% O2) or medical air (78.9% N2/21.1% O2) could reduce dyspnoea and improve the exercise capability of patients with primary lung cancer and dyspnoea on exertion (Borg >3). A total of 12 patients (seven male, five female patients, age 53–78) breathed the test gases in randomised order via a facemask and inspiratory demand valve at rest and while performing 6-min walk tests. Pulse oximetry (SaO2) was recorded continuously. Respiratory rate and dyspnoea ratings (Borg and VAS) were taken before and immediately post-walk. Breathing Heliox28 at rest significantly increased SaO2 compared to oxygen-enriched air (96±2 cf. 94±2, P<0.01). When compared to medical air, breathing Heliox28 but not oxygen-enriched air gave a significant improvement in the exercise capability (P<0.0001), SaO2 (P<0.05) and dyspnoea scores (VAS, P<0.05) of lung cancer patients.
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Affiliation(s)
- S H Ahmedzai
- Academic Palliative Medicine Unit, Clinical Sciences Division (South), Royal Hallamshire Hospital, Glossop Rd, Sheffield S10 2JF, UK
| | - E Laude
- Department of Biomedical Science, University of Sheffield, Alfred Denny Building, Western Bank, Sheffield S102TN, UK
- Academic Palliative Medicine Unit, Clinical Sciences Division (South), Royal Hallamshire Hospital, Glossop Rd, Sheffield S10 2JF, UK. E-mail:
| | - A Robertson
- Academic Palliative Medicine Unit, Clinical Sciences Division (South), Royal Hallamshire Hospital, Glossop Rd, Sheffield S10 2JF, UK
| | - G Troy
- Academic Palliative Medicine Unit, Clinical Sciences Division (South), Royal Hallamshire Hospital, Glossop Rd, Sheffield S10 2JF, UK
| | - V Vora
- Academic Palliative Medicine Unit, Clinical Sciences Division (South), Royal Hallamshire Hospital, Glossop Rd, Sheffield S10 2JF, UK
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Recent Literature. J Palliat Med 2002. [DOI: 10.1089/10966210260499168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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