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Dinis-Oliveira RJ. "Not everything that can be counted counts" in ethanol toxicological results: an antemortem and postmortem technical interpretation focusing on driving under the influence. Forensic Sci Res 2024; 9:owae023. [PMID: 39006154 PMCID: PMC11240237 DOI: 10.1093/fsr/owae023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 03/29/2024] [Indexed: 07/16/2024] Open
Abstract
Ethanol blood analysis is the most common request in forensic toxicology, and some studies point to positive results in approximately one-third of all unnatural deaths. However, distinguishing sober deaths from drunk deaths is not as simple as it may seem. This technical, clinical, and forensic interpretation is proposed to interpret the ethanol toxicological results, discussing several artefacts and pitfalls that must be considered, namely focusing on driving under the influence. This work is presented with a practical and objective approach, aiming to alleviate the complexities associated with clinical, physiological, pathophysiological, and toxicological aspects to enhance comprehension, practicality, and applicability of its content, especially to courts. Particularly the physical integrity of the body, the postmortem interval, putrefactive signs, anatomic place of blood collection, alternative samples such as vitreous humour and urine, the possibility of postmortem redistribution, the inclusion of preservatives in containers, and optimal temperature conditions of shipment are among some of the aspects to pay attention. Although several biomarkers related to postmortem microbial ethanol production have been proposed, their translation into forensic routine is slow to be implemented due to the uncertainties of their application and analytical difficulties. Specifically, in the interpretation of ethanol toxicological results, "not everything that can be counted counts and not everything that counts can be counted" (attributed to Albert Einstein).
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Affiliation(s)
- Ricardo Jorge Dinis-Oliveira
- Associate Laboratory i4HB - Institute for Health and Bioeconomy, University Institute of Health Sciences - CESPU, Gandra, Portugal
- UCIBIO - Research Unit on Applied Molecular Biosciences, Translational Toxicology Research Laboratory, University Institute of Health Sciences 1H-TOXRUN, IUCS-CESPU, Gandra, Portugal
- Department of Public Health and Forensic Sciences and Medical Education, Faculty of Medicine, University of Porto, Porto, Portugal
- FOREN - Forensic Science Experts, Lisbon, Portugal
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Yang C, Jiang J, Zhou J, Hitosug M, Wang Z. Traffic safety and public health in China - Past knowledge, current status, and future directions. ACCIDENT; ANALYSIS AND PREVENTION 2023; 192:107272. [PMID: 37683567 DOI: 10.1016/j.aap.2023.107272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 08/08/2023] [Accepted: 08/24/2023] [Indexed: 09/10/2023]
Abstract
Transportation-related harms have developed into a social disease, threatening public safety and health in China. We aimed to increase the global understanding of traffic safety and public health in China from past knowledge, current status, and future directions by collecting, collating, and analyzing the Chinese traffic incidents reported in the published literature. A systematic search of China National Knowledge Infrastructure, Weipu, and published articles referenced in PubMed, Web of Science and ProQuest between January 1, 1988 and April 30, 2023 was performed. China encountered the first recorded traffic accident as early as three thousand years ago in the Shang Dynasty. An increase in vehicle capacity and velocity increased the traffic risks during the transition from rickshaws and livestock to motor vehicles in varying traffic environments. Humans are not only the decisive factor of a large number of vehicles, traffic routes, and environmental variables, but also the victims at the end and starting point of traffic accidents. Injuries (mechanical force, burns) and diseases (traffic-related air pollution, noise) caused by traffic activities not only threaten public health, but also cause risks to safe driving. Analysis of traffic activities and biomarkers promotes the treatment of traffic injuries in ethology and medicine. China prepared for the construction of healthy transportation in the "decade of road safety" toward an estimation of worldwide road traffic injuries in 2030. Improvement of traffic safety concerning public health under the "Outline of the National Comprehensive Three-dimensional Transportation Network Planning" in China will propel the realization of worldwide traffic environmental advancement.
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Affiliation(s)
- Ce Yang
- State Key Laboratory of Trauma and Chemical Poisoning, Research Institute of Surgery, Research Institute of Traffic Medicine, Daping Hospital, Third Military Medical University, Chongqing 400042, PR China.
| | - Jianxin Jiang
- State Key Laboratory of Trauma and Chemical Poisoning, Research Institute of Surgery, Research Institute of Traffic Medicine, Daping Hospital, Third Military Medical University, Chongqing 400042, PR China
| | - Jihong Zhou
- State Key Laboratory of Trauma and Chemical Poisoning, Research Institute of Surgery, Research Institute of Traffic Medicine, Daping Hospital, Third Military Medical University, Chongqing 400042, PR China
| | - Masahito Hitosug
- Department of Legal Medicine, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Zhengguo Wang
- State Key Laboratory of Trauma and Chemical Poisoning, Research Institute of Surgery, Research Institute of Traffic Medicine, Daping Hospital, Third Military Medical University, Chongqing 400042, PR China; International Traffic Medicine Association, Bloomfield Hills, MI, USA.
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Porpiglia NM, Tagliaro F, Micciolo R, Canal L, Musile G, Bortolotti F. New evidence of high association between carbohydrate deficient transferrin (CDT) and alcohol-related road traffic accidents. A retrospective study on 929 injured drivers. Forensic Sci Int 2022; 340:111438. [PMID: 36029720 DOI: 10.1016/j.forsciint.2022.111438] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 08/18/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND It is well known that traffic injuries still represent one of the main causes of death and that high blood alcohol concentrations while driving significantly increase the occurrence of accidents. However, only limited literature on the correlation between chronic alcohol abuse and accident risk is available. The aim of the present study was to investigate the hypothesis of an association between elevated concentrations of carbohydrate deficient transferrin (CDT) and the occurrence of alcohol-related traffic accidents. METHODS The analytical determinations of BAC and CDT were performed following certified methods in HS-GC-FID and HPLC, respectively. For BAC, 0.50 g/L was used as cut-off, whereas 2.0% was used for CDT, according to the standardisation proposed by IFCC. A total of 929 drivers, tested for BAC at the time of hospital admission after a traffic accident, were classified into two groups: InjDr 1 (BAC ≤ 0.50 g/L) and InjDr 2 (BAC>0.50 g/L); all drivers were also tested for CDT. RESULTS InjDr 1 included 674 individuals, only 2.5% showing a CDT above the cutoff, whereas InjDr 2 group consisted of 255 subjects, 28.6% testing positive for CDT (Odds Ratio 15.5). When subdividing the InjDr group into increasing classes of CDT, a steady increase in the percentage of BAC-positive drivers was appreciated. Moreover, average BAC was found to parallel each class of CDT. CONCLUSIONS The reported data strongly support the use of CDT as a biomarker of increased risk of alcohol-related traffic accidents in the procedures of re-granting of the driving license upon confiscation for "drink driving".
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Affiliation(s)
- Nadia M Porpiglia
- Unit of Forensic Medicine, Department of Diagnostics and Public Health, University of Verona, Piazzale L. A. Scuro 10, 37134 Verona, VR, Italy.
| | - Franco Tagliaro
- Unit of Forensic Medicine, Department of Diagnostics and Public Health, University of Verona, Piazzale L. A. Scuro 10, 37134 Verona, VR, Italy; Institute Translational Medicine and Biotechnology, Sechenov First Moscow State Medical University, 2-4 Bolshaya Pirogovskaya Street, 119991 Moscow, Russia
| | - Rocco Micciolo
- Department of Psychology and Cognitive Sciences and Centre for Medical Sciences, University of Trento, Corso Bettini, 84, 38068 Rovereto, TN, Italy
| | - Luisa Canal
- Department of Psychology and Cognitive Sciences, University of Trento, Corso Bettini, 84, 38068 Rovereto, TN, Italy
| | - Giacomo Musile
- Unit of Forensic Medicine, Department of Diagnostics and Public Health, University of Verona, Piazzale L. A. Scuro 10, 37134 Verona, VR, Italy
| | - Federica Bortolotti
- Unit of Forensic Medicine, Department of Diagnostics and Public Health, University of Verona, Piazzale L. A. Scuro 10, 37134 Verona, VR, Italy
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CDT vs. GGT for the certification of the fitness to hold the driving license. A comparison based on the association of incremented values with the occurrence of alcohol-related road traffic accidents. Drug Alcohol Depend 2021; 228:109088. [PMID: 34619604 DOI: 10.1016/j.drugalcdep.2021.109088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND In the context of fitness certification to hold the driving license, GGT and CDT have been used, sometimes in combination (γ-CDT), to exclude chronic alcohol abuse. The present study was carried out with the aim of comparing the power of these biomarkers as tools for the objective screening of subjects at high risk of alcohol-associated traffic injuries. METHODS 288 male drivers admitted to hospital after traffic accidents were examined by determination of GGT, CDT and BAC. The degree of association of GGT, CDT and γ-CDT with BAC was analysed using non-parametric statistics. RESULTS Partitioning the cases using the cut-off concentrations of 0.5 g/L for BAC (the legal limit adopted in most European countries), 55 U/L for GGT and 1.9% for CDT, a highly significant difference was found between the frequency of elevated GGT or CDT in cases where BAC was within the legal limits and those with elevated BAC values (Fisher's exact test: p < 0.001). However, the calculation of the odds ratio showed a much higher increase for CDT (28 times) than for GGT (6 times) in those drivers with a BAC above the Italian legal limit in comparison with those showing a BAC within the cut-off; conversely, γ-CDT does not provide any significant advantage vs. CDT alone. CONCLUSIONS Both GGT and CDT provide objective evidence of an association with the occurrence of alcohol-related severe traffic accidents, but CDT shows superior association with these events. Therefore, CDT, notwithstanding higher costs, should be preferred in a forensic/certification context.
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Musile G, Pigaiani N, Sorio D, Colombari M, Bortolotti F, Tagliaro F. Alcohol-associated traffic injuries in Verona territory: A nine-year survey. MEDICINE, SCIENCE, AND THE LAW 2021; 61:7-13. [PMID: 33591874 DOI: 10.1177/0025802420937577] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
According to the World Health Organization, as many as 25% of traffic accidents are linked to alcohol abuse. This study describes the results of a nine-year study performed on injured drivers (N = 12,806) in the Verona area of Northern Italy. Blood samples were mandatorily collected on injured drivers who were admitted to the Emergency Health Care Unit of Verona Hospital between 2009 and 2017, after they had been involved in a traffic accident. Blood alcohol concentration (BAC) determination was then undertaken using a validated head space-gas chromatography-flame ionisation detector (HS-GC-FID) method. We found that 21% of drivers tested positive for alcohol (BAC ≥0.01 g/L), while 16.8% presented with BAC levels above the Italian legal limit (>0.5 g/L). Of those who had positive BACs, about 50% presented with very high BAC levels (>1.5 g/L). Daily time distribution analyses, involving 2031 alcohol-positive drivers, showed a surge between 18:00 hours and 06:00 hours (74.3%), with a specific rise during the weekend (58.9%). The percentage of alcohol-related road accidents was 20.6%, which is lower than results reported in other international studies performed over the last 20 years. However, evidence that around 50% of the positive subjects showed a BAC >1.5 g/L confirms the correlation between BAC and accident risk, which becomes even more significant at progressively increasing levels of BAC. The study highlights the need to implement further strategies to both prevent and deter the use of alcohol while driving.
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Affiliation(s)
- Giacomo Musile
- Department of Diagnostics and Public Health - Unit of Forensic Medicine, University of Verona, Italy
- Institute of Translational Medicine and Biotechnology, Sechenov First Moscow State Medical University, Russia
| | - Nicola Pigaiani
- Department of Diagnostics and Public Health - Unit of Forensic Medicine, University of Verona, Italy
| | - Daniela Sorio
- Department of Diagnostics and Public Health - Unit of Forensic Medicine, University of Verona, Italy
| | - Michela Colombari
- Department of Diagnostics and Public Health - Unit of Forensic Medicine, University of Verona, Italy
| | - Federica Bortolotti
- Department of Diagnostics and Public Health - Unit of Forensic Medicine, University of Verona, Italy
| | - Franco Tagliaro
- Department of Diagnostics and Public Health - Unit of Forensic Medicine, University of Verona, Italy
- Institute of Translational Medicine and Biotechnology, Sechenov First Moscow State Medical University, Russia
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Bortolotti F, Raffaelli R, Di Simone N, Semprebon M, Mirandola M, Simonetto C, De Marchi F, Trevisan MT, Carli G, Dorizzi RM, Scambia G, Franchi M, Tagliaro F. CDT reference values for monitoring chronic alcohol abuse in pregnancy. Clin Chim Acta 2020; 507:156-160. [PMID: 32302685 DOI: 10.1016/j.cca.2020.04.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 04/13/2020] [Accepted: 04/13/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND AIM Carbohydrate Deficient Transferrin (CDT) is one of the most used biomarkers for monitoring alcohol use in pregnancy. However, its effective application in this context is hampered by the demonstrated physiological progressive increase during pregnancy (even in abstinent women) of CDT values, which in the third trimester can reach values close or exceeding the cut-offs usually adopted in clinical and forensic diagnostics. The present work was aimed at the re-assessment of CDT reference values in pregnancy. MATERIALS AND METHODS The CDT analysis was performed by a validated HPLC-UV Vis method on 284 serum samples of women with a physiological pregnancy and on 370 sera of non-pregnant woman from the general population (control group). All the samples were tested also for GGT for excluding alcohol abuse. The statistical analysis was performed using the MedCalc® Statistical Software. RESULTS The re-definition of the specific reference concentrations was carried out according to the Horn and Pesce Robust Method. The resulting CDT upper reference values were 1.45%, 2.01% and 2.05% in the first, second, and third trimester, respectively. CONCLUSIONS In order to prevent the development of maternal and fetal prenatal alcohol exposure complications, the use of alcohol biomarkers, including CDT, has been proposed. However, this biomarker, in the monitoring of alcohol use in pregnancy, has so far been applied adopting the same cut-off used for general population without taking into consideration the progressive physiological increase of its value throughout the pregnancy. In the present study, a specific re-assessment of the CDT reference concentrations of each trimester is reported.
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Affiliation(s)
- Federica Bortolotti
- Dept. of Diagnostic and Public Health, Unit of Forensic Medicine, University of Verona, Verona, Italy.
| | - Ricciarda Raffaelli
- Dept. of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Nicoletta Di Simone
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Universita' Cattolica del S Cuore, Rome, Italy
| | - Michela Semprebon
- Dept. of Diagnostic and Public Health, Unit of Forensic Medicine, University of Verona, Verona, Italy
| | - Mariateresa Mirandola
- Dept. of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Chiara Simonetto
- Dept. of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Francesca De Marchi
- Dept. of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Maria Teresa Trevisan
- Laboratory of Clinical Chemistry and Microbiology, Hospital G. Fracastoro, Verona, Italy
| | - Giovanna Carli
- Service of Forensic Medicine, Integrated University Hospital of Verona, Verona, Italy
| | - Romolo M Dorizzi
- Dept. of Pathology, Transfusion & Laboratory Medicine, AUSL Romagna, Cesena, Italy
| | - Giovanni Scambia
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Universita' Cattolica del S Cuore, Rome, Italy
| | - Massimo Franchi
- Dept. of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Franco Tagliaro
- Dept. of Diagnostic and Public Health, Unit of Forensic Medicine, University of Verona, Verona, Italy; Institute of Translational Medicine and Biotechnology, Sechenov First Moscow State Medical University, Moscow, Russia
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Porpiglia NM, Bortolotti F, Dorizzi RM, Micciolo R, Tagliaro F. Critical Evaluation of the Association Between Elevated Mean Corpuscular Volume and Alcohol-Related Traffic Accidents: A Retrospective Study on 6244 Car Crash Cases. Alcohol Clin Exp Res 2019; 43:1528-1532. [PMID: 30986331 DOI: 10.1111/acer.14046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 03/27/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Erythrocyte mean corpuscular volume (MCV) has been used for decades as a biomarker of chronic alcohol abuse and in the treatment of alcohol dependence. More recently, it has also been adopted to investigate the fitness of subjects to hold the driving license to prevent traffic accidents. So far, however, the studies on the association of MCV with an increased risk of alcohol-associated car accidents are extremely scarce, if not totally absent. To the best of our knowledge, the present work is the first specifically aimed at studying a plausible association between elevated MCV and crash accidents correlated with alcohol abuse. METHODS A total of 6,244 drivers involved in traffic accidents underwent mandatory laboratory analyses including blood alcohol concentration (BAC) determination and MCV analysis. BAC and MCV determinations were performed by headspace gas chromatography and complete blood count, respectively. RESULTS The chi-square test evaluating the proportions of subjects with elevated MCVs (>95 fl) yielded a highly significant result (χ2 = 68.0; p < 0.001) in the blood samples where the BAC was above the legal limit (i.e., >0.5 g/l). However, when considering only drivers showing BACs in the range of 0.51 to 1.5 g/l, the frequencies of elevated MCV values are fairly comparable (χ2 = 0.062, p = 0.80). In contrast, limiting the evaluation to BACs > 1.5 g/l, the frequency of elevated MCVs raised to 19.1% (χ2 = 58.9, p value < 0.001 vs. the group with BAC within the legal limits). CONCLUSIONS The present observations show that MCV increases are typically associated with drivers involved in accidents only if driving under severe alcohol intoxication, leading to a preliminary conclusion that, in the context of the certification of the fitness to the driving license, MCV fails to reveal individuals at risk who tend to drive in a condition of low-to-moderate alcohol intoxication.
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Affiliation(s)
- Nadia M Porpiglia
- Department of Diagnostics and Public Health, Unit of Forensic Medicine, University of Verona, Verona, Italy
| | - Federica Bortolotti
- Department of Diagnostics and Public Health, Unit of Forensic Medicine, University of Verona, Verona, Italy
| | - Romolo M Dorizzi
- U.O. Patologia Clinica, Laboratorio Unico della Romagna, Cesena, Italy
| | - Rocco Micciolo
- Department of Psychology and Cognitive Sciences, University of Trento, Trento, Italy
| | - Franco Tagliaro
- Department of Diagnostics and Public Health, Unit of Forensic Medicine, University of Verona, Verona, Italy.,Institute Translational Medicine and Biotechnology, Sechenov First Moscow State Medical University, Moscow, Russia
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Bortolotti F, Sorio D, Bertaso A, Tagliaro F. Analytical and diagnostic aspects of carbohydrate deficient transferrin (CDT): A critical review over years 2007-2017. J Pharm Biomed Anal 2017; 147:2-12. [PMID: 28912047 DOI: 10.1016/j.jpba.2017.09.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 08/30/2017] [Accepted: 09/01/2017] [Indexed: 02/07/2023]
Abstract
The need for investigating alcohol abuse by means of objective tools is worldwide accepted. Among the currently available biomarkers of chronic alcohol abuse, carbohydrate-deficient transferrin (CDT) is one of the most used indicator, mainly because of its high specificity. However, some CDT analytical and interpretation aspects are still under discussion, as witnessed by numerous research papers and reviews. The present article presents a critical review of the literature on CDT appeared in the period from 2007 to 2017 (included). The article is organized in the following sections: (1) introduction, (2) pre-analytical aspects (3) analytical aspects (4) diagnostic aspects (5) concluding remarks. As many as 139 papers appeared in the international literature and retrieved by the search engines PubMed, Web of Science and Scopus are quoted.
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Affiliation(s)
- F Bortolotti
- Dept of Diagnostics and Public Health, Unit of Forensic Medicine, University of Verona, Italy.
| | - D Sorio
- Dept of Diagnostics and Public Health, Unit of Forensic Medicine, University of Verona, Italy
| | - A Bertaso
- Dept of Diagnostics and Public Health, Unit of Forensic Medicine, University of Verona, Italy
| | - F Tagliaro
- Dept of Diagnostics and Public Health, Unit of Forensic Medicine, University of Verona, Italy; Institute of Pharmacy and Translational Medicine, Sechenov First Medical University, Moskow, Russia
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Long-term stability of serum samples positive for carbohydrate deficient transferrin (CDT) routinely stored at −20 °C. ACTA ACUST UNITED AC 2016; 54:e285-7. [DOI: 10.1515/cclm-2016-0074] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 02/09/2016] [Indexed: 11/15/2022]
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