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O'Grady HK, Ball I, Berney S, Burns KEA, Cook DJ, Fox-Robichaud A, Herridge MS, Karachi T, Mathur S, Reid JC, Rochwerg B, Rollinson T, Rudkowski JC, Bosch J, Turkstra LS, Kho ME. Characterizing usual-care physical rehabilitation in Canadian intensive care unit patients: a secondary analysis of the Canadian multicentre Critical Care Cycling to Improve Lower Extremity Strength pilot randomized controlled trial. Can J Anaesth 2024; 71:1406-1416. [PMID: 39317833 DOI: 10.1007/s12630-024-02838-7] [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: 10/30/2023] [Revised: 04/19/2024] [Accepted: 04/20/2024] [Indexed: 09/26/2024] Open
Abstract
PURPOSE Physical rehabilitation (PR) in the intensive care unit (ICU) may improve outcomes for survivors but clinical trial results have been discordant. We hypothesized that discordant results may reflect treatment heterogeneity received by "usual care" comparator groups in PR studies. Usual-care PR is typically underspecified, which is a barrier to comparing results across treatment studies. The primary objective of the present study was to describe the usual-care PR received by critically ill patients enrolled in the Canadian multicentre Critical Care Cycling to Improve Lower Extremity Strength (CYCLE) pilot randomized controlled trial (RCT) of PR. Other objectives were to help contextualize current research and provide data for international comparison. METHODS In this secondary analysis of the CYCLE pilot RCT, patients were randomized to in-bed cycling and usual-care PR or usual-care PR alone. Physiotherapists documented usual-care PR including therapy received, type of activity, duration, adverse events and consequences, reasons for no PR, and concurrent relevant medical interventions. We characterized usual care using descriptive statistics at the cohort and patient levels. RESULTS Across seven Canadian centres, 30 patients were randomized to usual-care PR. The median [interquartile range (IQR)] ICU stay was 10 [9-24] days and patients received PR on a median [IQR] of 5 [3-9] days for 23 [17-30] min per day. Eighteen patients (60%) stood, marched, or walked during usual care. Transient adverse events occurred in three patients on 1.5% (3/198) of days and none prompted session termination. CONCLUSIONS In the usual-care arm of the CYCLE pilot RCT, PR was delivered on half of ICU days and over half of patients stood, marched, or walked. Adverse events during usual-care PR were uncommon. STUDY REGISTRATION ClinicalTrials.gov ( NCT02377830 ); first posted 4 March 2015.
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Affiliation(s)
- Heather K O'Grady
- School of Rehabilitation Science, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Ian Ball
- Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Sue Berney
- Physiotherapy Clinic, Austin Health, Heidelberg, VIC, Australia
- Department of Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, Parkville, VIC, Australia
| | - Karen E A Burns
- Li Sha King Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Deborah J Cook
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact (HEI), Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Alison Fox-Robichaud
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Margaret S Herridge
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Timothy Karachi
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Sunita Mathur
- School of Rehabilitation Therapy, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
| | - Julie C Reid
- Department of Health Research Methods, Evidence, and Impact (HEI), Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact (HEI), Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Thomas Rollinson
- Physiotherapy Clinic, Austin Health, Heidelberg, VIC, Australia
- Department of Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, Parkville, VIC, Australia
| | - Jill C Rudkowski
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Jackie Bosch
- School of Rehabilitation Science, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Lyn S Turkstra
- School of Rehabilitation Science, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Michelle E Kho
- School of Rehabilitation Science, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.
- Physiotherapy Department, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada.
- Institute of Applied Health Sciences, 1400 Main St. W., Hamilton, ON, L8S 1C7, Canada.
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Ramalho F, Oliveira A, Machado A, Azevedo V, Gonçalves MR, Ntoumenopoulos G, Marques A. Physiotherapists in intensive care units: Where are we? Pulmonology 2024; 30:319-323. [PMID: 38413343 DOI: 10.1016/j.pulmoe.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/02/2024] [Accepted: 02/05/2024] [Indexed: 02/29/2024] Open
Affiliation(s)
- F Ramalho
- Lab3R - Respiratory Research and Rehabilitation Laboratory, School of Health Sciences, University of Aveiro (ESSUA), Aveiro, Portugal; Hospital Professor Doutor Fernando Fonseca, Lisbon, Portugal
| | - A Oliveira
- Lab3R - Respiratory Research and Rehabilitation Laboratory, School of Health Sciences, University of Aveiro (ESSUA), Aveiro, Portugal; iBiMED - Institute of Biomedicine, Department of Medical Sciences, University of Aveiro, Aveiro, Portugal; School of Rehabilitation Sciences, McMaster University, Canada
| | - A Machado
- Lab3R - Respiratory Research and Rehabilitation Laboratory, School of Health Sciences, University of Aveiro (ESSUA), Aveiro, Portugal; iBiMED - Institute of Biomedicine, Department of Medical Sciences, University of Aveiro, Aveiro, Portugal
| | - V Azevedo
- Centro Hospitalar Lisboa Ocidental - Egas Moniz Hospital - Polyvalent Intensive Care Unit, Alcoitão School of Health Sciences, Lisbon, Portugal
| | - M R Gonçalves
- Noninvasive Ventilatory Support Unit, Emergency and Intensive Care Medicine Department, Pulmonology Department, São João University Hospital. Faculty of Medicine, University of Porto, Portugal
| | - G Ntoumenopoulos
- Department of Physiotherapy, St Vincent's Hospital, Sydney, Australia
| | - A Marques
- Lab3R - Respiratory Research and Rehabilitation Laboratory, School of Health Sciences, University of Aveiro (ESSUA), Aveiro, Portugal; iBiMED - Institute of Biomedicine, Department of Medical Sciences, University of Aveiro, Aveiro, Portugal.
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Shkurka E, Wray J, Peters MJ, Shannon H. Chest physiotherapy for mechanically ventilated children: a survey of current UK practice. Physiotherapy 2022; 119:17-25. [PMID: 36706622 DOI: 10.1016/j.physio.2022.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 11/02/2022] [Accepted: 11/12/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Chest physiotherapy is a treatment option for mechanically ventilated children. However, there is a lack of consensus regarding its value and informal discussions suggest variation in practice. This study describes chest physiotherapy practices for mechanically ventilated children in the UK and explores clinical decision making related to its delivery. DESIGN Cross-sectional study, using an anonymous, electronic survey. PARTICIPANTS Qualified physiotherapists working in UK NHS paediatric intensive care units (PICUs). RESULTS The response rate was 61% (72/118), this included physiotherapists from 26/27 (96%) PICUs. All participants reported using manual hyperinflations and position changes 'always' or 'often'. Variation in practice was evident for some techniques, including Metaneb® and percussion. DNase (99%, 71/72) and hypertonic saline (90%, 65/72) were the most frequently used mucoactives: 91% (59/65) of physiotherapists reported only nebulising hypertonic saline and 69% (49/71) use both nebulised and instilled DNase. Use and delivery of N-acetylcysteine was inconsistent (nebulised only 55%, 26/47; instilled only 15%, 7/47; both 30%, 14/47). Chest physiotherapy was most commonly delivered with a nurse (67%, 48/72). Clinical decision making processes were comparable between physiotherapists and encompassed three main elements: individual patient assessment, involvement of the multidisciplinary team, and risk versus benefit analysis. CONCLUSIONS A range of chest physiotherapy treatments and adjuncts were used with ventilated children. Variation was apparent and may be due to individual preferences of those training staff or local policies. Pragmatic, interventional studies are required to determine best practice. Further exploration is necessary to understand the variation in practice and intricacies of decision making.
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Affiliation(s)
- Emma Shkurka
- Physiotherapy Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; Infection, Immunity & Inflammation Department, UCL Great Ormond Street Institute of Child Health, London, UK.
| | - Jo Wray
- Centre for Outcomes and Experience Research in Children's Health, Illness and Disability, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Mark J Peters
- Infection, Immunity & Inflammation Department, UCL Great Ormond Street Institute of Child Health, London, UK; Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Harriet Shannon
- Infection, Immunity & Inflammation Department, UCL Great Ormond Street Institute of Child Health, London, UK
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Connolly B, Barclay M, Blackwood B, Bradley J, Anand R, Borthwick M, Chikhani M, Dark P, Shyamsundar M, Warburton J, McAuley DF, O'Neill B. Airway clearance techniques and use of mucoactive agents for adult critically ill patients with acute respiratory failure: a qualitative study exploring UK physiotherapy practice. Physiotherapy 2020; 108:78-87. [PMID: 32721607 DOI: 10.1016/j.physio.2020.06.003] [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: 08/01/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To explore and describe current UK physiotherapy practice relating to airway clearance techniques and mucoactive agents in critically ill adult patients with acute respiratory failure in the intensive care unit. DESIGN A descriptive, qualitative study using focus group interviews. Focus groups were audio-recorded, independently transcribed, and data analysed thematically. Participants Senior, experienced physiotherapists, clinically active in critical care. RESULTS Fifteen physiotherapists participated in four interview sessions. Five themes emerged describing airway clearance techniques: 'Repertoire of airway clearance techniques', 'Staffing and skillset', 'Commencing respiratory physiotherapy', 'Technique selection', and 'Determining effectiveness' were themes related to airway clearance techniques. Five themes were also identified in relation to mucoactive agents: 'Use in clinical practice', 'Decision to commence', 'Selection of agent', 'Stopping mucoactive agents', and 'Determining effectiveness'. A summary of key features of standard practice was developed. CONCLUSIONS Standard UK physiotherapy practice of airway clearance techniques is variable, but patient-centred and targeted to individual need, with adjunctive use of mucoactive agents to enhance and optimise patient management if required. Based on this study, key features of airway clearance techniques have been summarised to help capture standard care, which could be used in future trials involving ACT as part of usual care.
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Affiliation(s)
- Bronwen Connolly
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK; Lane Fox Clinical Respiratory Physiology Research Centre, Guy's and St. Thomas' NHS Foundation Trust, London, UK; Centre for Human and Applied Physiological Sciences, King's College London, London, UK; Department of Physiotherapy, The University of Melbourne, Australia.
| | - Matthew Barclay
- Lane Fox Clinical Respiratory Physiology Research Centre, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Judy Bradley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Rohan Anand
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Mark Borthwick
- John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Marc Chikhani
- Nottingham University Hospitals NHS Trust, Nottingham, UK; Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Paul Dark
- Division of Infection, Immunity and Respiratory Medicine, NIHR Biomedical Research Centre, Manchester University NHS Foundation Trust, University of Manchester, Manchester, UK
| | - Murali Shyamsundar
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - John Warburton
- Bristol Royal Infirmary, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Brenda O'Neill
- Centre for Health and Rehabilitation Technologies, Institute of Nursing and Health Research, Ulster University, Newtownabbey, UK. https://twitter.com/@OneillBon
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Tadyanemhandu C, Mukombachoto R, Nhunzvi C, Kaseke F, Chikwasha V, Chengetanai S, Manie S. The prevalence of pulmonary complications after thoracic and abdominal surgery and associated risk factors in patients admitted at a government hospital in Harare, Zimbabwe-a retrospective study. Perioper Med (Lond) 2017; 6:11. [PMID: 28852474 PMCID: PMC5567626 DOI: 10.1186/s13741-017-0066-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Accepted: 08/03/2017] [Indexed: 01/01/2023] Open
Abstract
Background The burden of HIV/AIDS in Sub-Saharan Africa has presented unusual and challenging acute surgical problems across all specialties. Thoraco-abdominal surgery cuts through muscle and thereby disrupts the normal anatomy and activity of the respiratory muscles leading to reduced lung volumes and putting the patients at greater risk of developing post-operative pulmonary complications (PPCs). PPCs remain an important cause of post-operative morbidity, mortality, and impacts on the long-term outcomes of patients post hospital discharge. The objective of the study was to determine the pulmonary complications developing after abdominal and thoracic surgery and the associated risks factors. Methods A retrospective records review of all abdominal and thoracic surgery patients admitted at a central hospital from January 2014 to October 2014 was done. Data collected included demographic data, surgical history, comorbidities and the PPCs present. Results Out of the 92 patients whose records were reviewed, 55 (59.8%) were males and 84 (91.3%) had abdominal surgery. The mean age of the patients was 42.6 years (SD = 18.4). The common comorbidities were HIV infection noted in 14(15.2%) of the patients and hypertension in 10 (13.0%). Thirty nine (42.4%) developed PPCs and the most common complications were nosocomial pneumonia in 21 (22.8%) patients, ventilator associated pneumonia in 11 (12.0%), and atelectasis in 6 (6.5%) patients. Logistic regression showed that a history of alcohol consumption, prolonged surgery, prolonged stay in hospital or critical care unit, incision type, and comorbidities were significant risk factors for PPCs (p < 0.05). The mortality rate was 10.9%. Conclusion PPCs like nosocomial and ventilator associated pneumonia were common and were associated with increased morbidity and adversely affected clinical outcomes of patients. HIV and hypertension presented significant comorbidities which the health team needed to recognize and address. Strategies to reduce the occurrence of PPCs have to be implemented through coordinated efforts by the health practitioners as a team during the entire perioperative period.
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Affiliation(s)
- Cathrine Tadyanemhandu
- Department of Rehabilitation, College of Health Sciences, University Of Zimbabwe, PO Box AV 178, Avondale, Harare, Zimbabwe
| | - Rufaro Mukombachoto
- Department of Rehabilitation, College of Health Sciences, University Of Zimbabwe, PO Box AV 178, Avondale, Harare, Zimbabwe
| | - Clement Nhunzvi
- Department of Rehabilitation, College of Health Sciences, University Of Zimbabwe, PO Box AV 178, Avondale, Harare, Zimbabwe
| | - Farayi Kaseke
- Department of Rehabilitation, College of Health Sciences, University Of Zimbabwe, PO Box AV 178, Avondale, Harare, Zimbabwe
| | - Vasco Chikwasha
- Department of Community Medicine, College of Health Sciences, University Of Zimbabwe, PO Box AV 178, Avondale, Harare, Zimbabwe
| | - Samson Chengetanai
- Division of Basic Medical Sciences, Faculty of Medicine, National University of Science and Technology, PO Box AC 939, Ascot, Bulawayo, Zimbabwe
| | - Shamila Manie
- Division of Physiotherapy, Department of Health and Rehabilitation Sciences, Faculty of Health Sciences, University of CapeTown, Anzio Road, Observatory, CapeTown, South Africa
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Factors influencing physical activity and rehabilitation in survivors of critical illness: a systematic review of quantitative and qualitative studies. Intensive Care Med 2017; 43:531-542. [PMID: 28210771 DOI: 10.1007/s00134-017-4685-4] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 01/10/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE To identify, evaluate and synthesise studies examining the barriers and enablers for survivors of critical illness to participate in physical activity in the ICU and post-ICU settings from the perspective of patients, caregivers and healthcare providers. METHODS Systematic review of articles using five electronic databases: MEDLINE, CINAHL, EMBASE, Cochrane Library, Scopus. Quantitative and qualitative studies that were published in English in a peer-reviewed journal and assessed barriers or enablers for survivors of critical illness to perform physical activity were included. Prospero ID: CRD42016035454. RESULTS Eighty-nine papers were included. Five major themes and 28 sub-themes were identified, encompassing: (1) patient physical and psychological capability to perform physical activity, including delirium, sedation, illness severity, comorbidities, weakness, anxiety, confidence and motivation; (2) safety influences, including physiological stability and concern for lines, e.g. risk of dislodgement; (3) culture and team influences, including leadership, interprofessional communication, administrative buy-in, clinician expertise and knowledge; (4) motivation and beliefs regarding the benefits/risks; and (5) environmental influences, including funding, access to rehabilitation programs, staffing and equipment. CONCLUSIONS The main barriers identified were patient physical and psychological capability to perform physical activity, safety concerns, lack of leadership and ICU culture of mobility, lack of interprofessional communication, expertise and knowledge, and lack of staffing/equipment and funding to provide rehabilitation programs. Barriers and enablers are multidimensional and span diverse factors. The majority of these barriers are modifiable and can be targeted in future clinical practice.
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Tadyanemhandu C, Manie S. Implementation of the physical function ICU test tool in a resource constrained intensive care unit to promote early mobilisation of critically ill patients- a feasibility study. Arch Physiother 2016; 6:12. [PMID: 29340193 PMCID: PMC5759917 DOI: 10.1186/s40945-016-0026-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 10/06/2016] [Indexed: 12/21/2022] Open
Abstract
Background The shift of focus in outcome measures from mortality to assessment of functional status in intensive care unit (ICU) patients has resulted in the emergence of mobilisation of critically ill patients as a standard physiotherapy practice in most medium and high income countries. The aim of this study was to determine the feasibility of an early mobilisation program and to report on the changes in patient clinical outcomes following the intervention in a low income country. Methods A prospective cohort study was carried out at one public hospital. An adult cohort of 35 patients was recruited within 24 h of being admitted into the unit, irrespective of ventilation method over a period of three months. An early mobilisation programme was implemented and prescribed using the Physical Function ICU Test (PFIT-s) which commenced in either the ICU or high dependent unit. Results The median age of the 35 patients was 29 years (IQR = 24–45 years). More than half of the patients had undergone surgery due to either gastrointestinal problems or obstetrical complications. A total of 94 out of a possible of 219 exercise sessions were delivered to the patients (43.0 %). The tool was implemented in 32 (91.4 %) patients on the initial PFIT-s measurement and 16 (45.7 %) of the patients required the assistance of two people to stand. The Initial PFIT-s mean score was 5.3 ± 1.8. On final PFIT-s measurement, out of the 30 (85.7 %) patients seen, 15 (42.9 %) of the patients did not require any assistance to stand and the final PFIT-s mean score was 7.0 ± 1.9. There was a significant difference in both the initial PFIT-s total score (t-value = 2.34, df = 30, p = .03) and the final PFIT-s score (t-value = 3.66, df = 28, p = .001) between males and females. During the treatment, no adverse event occurred in any of the patients. Conclusion An early mobilisation program using PFIT-s was feasible and safe. There was a difference in functional capability based on gender, with males being more functionally active. Specific inclusion and exclusion criteria can lead to a delayed early mobilisation activities in ICU patients. Trial registration Pan African Clinical Trials Registry PACTR201408000829202. Registered 15 August 2014.
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Affiliation(s)
- Cathrine Tadyanemhandu
- Department of Rehabilitation, College of Health Sciences, University of Zimbabwe, PO Box AV 178. Avondale, Harare, Zimbabwe
| | - Shamila Manie
- Department of Health and Rehabilitation Sciences, Faculty of Health Sciences, Division of Physiotherapy, University of Cape Town, Anzio Road, Observatory, Cape Town, South Africa
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