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Knoph CS, Cook ME, Novovic S, Hansen MB, Mortensen MB, Nielsen LBJ, Høgsberg IM, Salomon C, Neergaard CEL, Aajwad AJ, Pandanaboyana S, Sørensen LS, Thorlacius-Ussing O, Frøkjær JB, Olesen SS, Drewes AM. No Effect of Methylnaltrexone on Acute Pancreatitis Severity: A Multicenter Randomized Controlled Trial. Am J Gastroenterol 2024:00000434-990000000-01208. [PMID: 38916223 DOI: 10.14309/ajg.0000000000002904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 06/06/2024] [Indexed: 06/26/2024]
Abstract
INTRODUCTION Opioids used to manage severe pain in acute pancreatitis (AP) might exacerbate the disease through effects on gastrointestinal and immune functions. Methylnaltrexone, a peripherally acting µ-opioid receptor antagonist, may counteract these effects without changing analgesia. METHODS This double-blind, randomized, placebo-controlled trial included adult patients with AP and systemic inflammatory response syndrome at 4 Danish centers. Patients were randomized to receive 5 days of continuous intravenous methylnaltrexone (0.15 mg/kg/d) or placebo added to the standard of care. The primary end point was the Pancreatitis Activity Scoring System score after 48 hours of treatment. Main secondary outcomes included pain scores, opioid use, disease severity, and mortality. RESULTS In total, 105 patients (54% men) were randomized to methylnaltrexone (n = 51) or placebo (n = 54). After 48 hours, the Pancreatitis Activity Scoring System score was 134.3 points in the methylnaltrexone group and 130.5 points in the placebo group (difference 3.8, 95% confidence interval [CI] -40.1 to 47.6; P = 0.87). At 48 hours, we found no differences between the groups in pain severity (0.0, 95% CI -0.8 to 0.9; P = 0.94), pain interference (-0.3, 95% CI -1.4 to 0.8; P = 0.55), and morphine equivalent doses (6.5 mg, 95% CI -2.1 to 15.2; P = 0.14). Methylnaltrexone also did not affect the risk of severe disease (8%, 95% CI -11 to 28; P = 0.38) and mortality (6%, 95% CI -1 to 12; P = 0.11). The medication was well tolerated. DISCUSSION Methylnaltrexone treatment did not achieve superiority over placebo for reducing the severity of AP.
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Affiliation(s)
- Cecilie Siggaard Knoph
- Mech-Sense and Centre for Pancreatic Diseases, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Mathias Ellgaard Cook
- Mech-Sense and Centre for Pancreatic Diseases, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Srdan Novovic
- Pancreatitis Centre East, Gastro Unit, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Mark Berner Hansen
- Digestive Disease Centre K, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Michael Bau Mortensen
- Odense Pancreas Centre, HPB Section, Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Liv Bjerre Juul Nielsen
- Digestive Disease Centre K, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Irene Maria Høgsberg
- Odense Pancreas Centre, HPB Section, Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Celina Salomon
- Department of Surgery A4, Odense University Hospital, Svendborg, Denmark
| | | | | | | | | | | | - Jens Brøndum Frøkjær
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Schou Olesen
- Mech-Sense and Centre for Pancreatic Diseases, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense and Centre for Pancreatic Diseases, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Essmat N, Karádi DÁ, Zádor F, Király K, Fürst S, Al-Khrasani M. Insights into the Current and Possible Future Use of Opioid Antagonists in Relation to Opioid-Induced Constipation and Dysbiosis. Molecules 2023; 28:7766. [PMID: 38067494 PMCID: PMC10708112 DOI: 10.3390/molecules28237766] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/21/2023] [Accepted: 11/22/2023] [Indexed: 12/18/2023] Open
Abstract
Opioid receptor agonists, particularly those that activate µ-opioid receptors (MORs), are essential analgesic agents for acute or chronic mild to severe pain treatment. However, their use has raised concerns including, among others, intestinal dysbiosis. In addition, growing data on constipation-evoked intestinal dysbiosis have been reported. Opioid-induced constipation (OIC) creates an obstacle to continuing treatment with opioid analgesics. When non-opioid therapies fail to overcome the OIC, opioid antagonists with peripheral, fast first-pass metabolism, and gastrointestinal localized effects remain the drug of choice for OIC, which are discussed here. At first glance, their use seems to only be restricted to constipation, however, recent data on OIC-related dysbiosis and its contribution to the appearance of several opioid side effects has garnered a great of attention from researchers. Peripheral MORs have also been considered as a future target for opioid analgesics with limited central side effects. The properties of MOR antagonists counteracting OIC, and with limited influence on central and possibly peripheral MOR-mediated antinociception, will be highlighted. A new concept is also proposed for developing gut-selective MOR antagonists to treat or restore OIC while keeping peripheral antinociception unaffected. The impact of opioid antagonists on OIC in relation to changes in the gut microbiome is included.
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Affiliation(s)
- Nariman Essmat
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, Semmelweis University, Nagyvárad tér 4, H-1445 Budapest, Hungary; (N.E.); (D.Á.K.); (F.Z.); (K.K.); (S.F.)
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Zagazig University, Zagazig 44519, Egypt
| | - Dávid Árpád Karádi
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, Semmelweis University, Nagyvárad tér 4, H-1445 Budapest, Hungary; (N.E.); (D.Á.K.); (F.Z.); (K.K.); (S.F.)
| | - Ferenc Zádor
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, Semmelweis University, Nagyvárad tér 4, H-1445 Budapest, Hungary; (N.E.); (D.Á.K.); (F.Z.); (K.K.); (S.F.)
| | - Kornél Király
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, Semmelweis University, Nagyvárad tér 4, H-1445 Budapest, Hungary; (N.E.); (D.Á.K.); (F.Z.); (K.K.); (S.F.)
| | - Susanna Fürst
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, Semmelweis University, Nagyvárad tér 4, H-1445 Budapest, Hungary; (N.E.); (D.Á.K.); (F.Z.); (K.K.); (S.F.)
| | - Mahmoud Al-Khrasani
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, Semmelweis University, Nagyvárad tér 4, H-1445 Budapest, Hungary; (N.E.); (D.Á.K.); (F.Z.); (K.K.); (S.F.)
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Insights into the Use of Peripherally Acting μ-Opioid Receptor Antagonists (PAMORAs) in Oncologic Patients: from Scientific Evidence to Real Clinical Practice. Curr Treat Options Oncol 2021; 22:26. [PMID: 33635493 DOI: 10.1007/s11864-021-00816-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2021] [Indexed: 12/17/2022]
Abstract
OPINION STATEMENT Management of chronic pain is crucial to improve the quality of life of cancer and palliative care patients. Opioid-based treatments used to control pain can be prolonged over time. Unfortunately, constipation is one of the most disturbing adverse effects of long-term use of opioids. Opioid-induced constipation (OIC) occurs when opioids bind to the specific receptors present in the gastrointestinal (GI) tract, and can affect any patients receiving chronic opioid therapy, including cancer patients. The limited efficacy of laxatives to treat OIC symptoms prompted the search for new therapeutic strategies. Peripherally acting μ-opioid receptor antagonists (PAMORAs) have recently emerged as new effective drugs for OIC management due to their specific binding to enteric μ-receptors. Little information is available on the use of PAMORAs in real-life practice for OIC treatment in cancer patients. In this paper, a panel of experts specializing in cancer and palliative care pools their clinical experience with PAMORAs in cancer patients presenting OIC and highlights the importance of timing and choice of therapy in achieving prompt OIC management and benefitting patients.
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Holm M, Tornvall P, Henareh L, Jensen U, Golster N, Alström P, Santos-Pardo I, Witt N, Fedchenko N, Venetsanos D, Beck O, van der Linden J. The MOVEMENT Trial. J Am Heart Assoc 2020; 8:e010152. [PMID: 30636504 PMCID: PMC6497337 DOI: 10.1161/jaha.118.010152] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Morphine administration is a strong predictor of delayed onset of action of orally administered ticagrelor in patients with ST‐segment–elevation myocardial infarction, likely because of impaired gastrointestinal motility. The aim of this study was to evaluate whether the peripheral opioid antagonist methylnaltrexone could improve pharmacodynamics and pharmacokinetics of orally administered ticagrelor in patients with ST‐segment–elevation myocardial infarction receiving morphine. Methods and Results The MOVEMENT (Methylnaltrexone to Improve Platelet Inhibition of Ticagrelor in Morphine‐Treated Patients With ST‐Segment Elevation Myocardial Infarction) trial was a multicenter, prospective, randomized, controlled trial in patients with ST‐segment–elevation myocardial infarction treated with morphine and ticagrelor. Upon arrival to the catheterization laboratory, patients were randomized to a blinded intravenous injection of either methylnaltrexone (8 or 12 mg according to weight) or 0.9% sodium chloride. The proportion of patients with high on‐treatment platelet reactivity and plasma concentrations of ticagrelor and AR‐C124910XX were assessed at baseline (arrival in the catheterization laboratory) and 1 and 2 hours later. A total of 82 patients received either methylnaltrexone (n=43) or placebo (n=39). Median (interquartile range) time from ticagrelor administration to randomization was 41 (31–50) versus 45.5 (37–60) minutes (P=0.16). Intravenous methylnaltrexone administration did not significantly affect prevalence of high on‐treatment platelet reactivity at 2 hours after inclusion, the primary end point, when compared with placebo (54% versus 51%, P=0.84). Plasma concentrations of ticagrelor and its active metabolite, the prespecified secondary end points, did not differ significantly between the groups over time. There was no significant difference in patient self‐estimated pain between the groups. Conclusions Methylnaltrexone did not significantly improve platelet reactivity or plasma concentrations of orally administered ticagrelor in patients with ST‐segment–elevation myocardial infarction receiving morphine. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02942550.
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Affiliation(s)
- Manne Holm
- 1 Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden.,2 Perioperative Medicine and Intensive Care, B31 Karolinska University Hospital Huddinge, Stockholm Sweden
| | - Per Tornvall
- 3 Unit of Cardiology Department of Clinical Science and Education Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Loghman Henareh
- 4 Coronary Artery and Vascular Disease Heart and Vascular Theme Department of Medicine Karolinska Institute and Karolinska University Hospital Stockholm Sweden
| | - Ulf Jensen
- 3 Unit of Cardiology Department of Clinical Science and Education Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Nanna Golster
- 1 Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
| | - Patrik Alström
- 3 Unit of Cardiology Department of Clinical Science and Education Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Irene Santos-Pardo
- 3 Unit of Cardiology Department of Clinical Science and Education Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Nils Witt
- 3 Unit of Cardiology Department of Clinical Science and Education Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Nikolai Fedchenko
- 3 Unit of Cardiology Department of Clinical Science and Education Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Dimitrios Venetsanos
- 4 Coronary Artery and Vascular Disease Heart and Vascular Theme Department of Medicine Karolinska Institute and Karolinska University Hospital Stockholm Sweden
| | - Olof Beck
- 5 Department of Laboratory Medicine Karolinska Institutet Stockholm Sweden
| | - Jan van der Linden
- 1 Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
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Franchi F, Rollini F, Park Y, Hu J, Kureti M, Rivas Rios J, Faz G, Yaranov D, Been L, Pineda AM, Suryadevara S, Soffer D, Zenni MM, Bass TA, Angiolillo DJ. Effects of Methylnaltrexone on Ticagrelor-Induced Antiplatelet Effects in Coronary Artery Disease Patients Treated With Morphine. JACC Cardiovasc Interv 2019; 12:1538-1549. [PMID: 31377269 DOI: 10.1016/j.jcin.2019.05.028] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 05/17/2019] [Accepted: 05/20/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The aim of this study was to assess if intravenous methylnaltrexone can counteract the effects of morphine on the pharmacokinetic (PK) and pharmacodynamic (PD) profiles of ticagrelor. BACKGROUND Morphine delays the onset of action of oral P2Y12 receptor inhibitors, including ticagrelor, by inhibiting gastric emptying and leading to delayed drug absorption. Methylnaltrexone is a peripheral opioid receptor antagonist that has the potential to prevent opioid-induced peripherally mediated side effects (e.g., gastric emptying inhibition) without affecting analgesia. METHODS In this prospective, randomized, double-blind, placebo-controlled, crossover study, aspirin-treated patients with stable coronary artery disease (n = 30) were randomized to receive methylnaltrexone (0.3 mg/kg intravenous) or matching placebo. After methylnaltrexone or placebo administration, all patients received morphine (5 mg intravenous). This was followed 15 min later by a 180-mg loading dose of ticagrelor. Patients crossed over to the alternative study treatment after 7 ± 2 days of washout. PK and PD assessments were performed at 12 time points (6 pre- and 6 post-crossover). PK analysis included measurement of plasma levels of ticagrelor and its major active metabolite (AR-C124910XX). PD assessments included VerifyNow P2Y12, light transmittance aggregometry, and vasodilator-stimulated phosphoprotein. RESULTS Only marginal changes in plasma levels of ticagrelor (and its major active metabolite) were observed with ticagrelor: maximum plasma concentration and area under the plasma concentration versus time curve from time 0 to the last measurable concentration were 38% and 30% higher, respectively, in patients receiving methylnaltrexone compared with those receiving placebo, but no differences in time to maximum plasma concentration were observed. There were no differences in P2Y12 reaction units by VerifyNow P2Y12 between groups at each time point, including 2 h (the primary endpoint; p = 0.261). Similarly, there were no differences in PD markers assessed by light transmittance aggregometry and vasodilator-stimulated phosphoprotein. CONCLUSIONS In patients with coronary artery disease receiving morphine, intravenous administration of the peripheral opioid receptor antagonist methylnaltrexone leads to only marginal changes in plasma levels of ticagrelor and its major metabolite, without affecting levels of platelet reactivity. (Effect of Methylnaltrexone on the PK/PD Profiles of Ticagrelor in Patients Treated With Morphine; NCT02403830).
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Affiliation(s)
- Francesco Franchi
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Fabiana Rollini
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Yongwhi Park
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Jenny Hu
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Megha Kureti
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Jose Rivas Rios
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Gabriel Faz
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Dmitry Yaranov
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Latonya Been
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Andres M Pineda
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Siva Suryadevara
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Daniel Soffer
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Martin M Zenni
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Theodore A Bass
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
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Raffa RB, Taylor R, Pergolizzi JV. Treating opioid‐induced constipation in patients taking other medications: Avoiding CYP450 drug interactions. J Clin Pharm Ther 2019; 44:361-371. [DOI: 10.1111/jcpt.12812] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 01/15/2019] [Accepted: 01/18/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Robert B. Raffa
- University of Arizona College of Pharmacy Tucson Arizona
- Temple University School of Pharmacy Philadelphia Pennsylvania
- Neumentum Inc Palo Alto California
- The NEMA Research Group Naples Florida
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Abstract
SummaryPatients with difficult venous access or oral intolerance and clinical situations with inadequate response to oral therapy have generated the need for alternative routes of delivery for drugs and fluids.The purpose of this study was to conduct a systematic review examining the evidence for subcutaneous (SC) administration of drugs and/or fluids.We used a broad search strategy using electronic databases CINAHL, EMBASE, PubMed and Cochrane library, key terms and ‘Medical Subject Headings’ (MeSH) such as ‘subcutaneous route’, ‘hypodermoclysis’ and the name/group of the most used drugs via this route (e.g. ‘ketorolac, morphine, ceftriaxone’, ‘analgesics, opioids, antibiotics’).We conclude that the SC route is an effective alternative for rehydration in patients with mild–moderate dehydration and offers a number of potential advantages in appropriately selected scenarios. Experience of administering drugs by this route suggests that it is well tolerated and is associated with minimal side-effects.
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Gibson PR, Morrison G. Effects of methylnaltrexone in patients with narcotic bowel syndrome: a pilot observational study. Intern Med J 2013; 42:907-12. [PMID: 22289023 DOI: 10.1111/j.1445-5994.2012.02726.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Narcotic bowel syndrome (NBS) describes disabling chronic severe abdominal pain that worsens despite continuing or escalating doses of opiates. Therapy is very limited. AIM To examine effects of blocking peripheral µ-opioid receptors on the symptomatology of patients with NBS and its safety. METHODS An open-label observational study was performed in four women with NBS. After a 2-week run-in period, patients were treated for 12 weeks with 8-12 mg methylnaltrexone bromide subcutaneously every other day, increasing to daily if there was poor response. Patient and physician assessment was documented, and patients completed an eight-symptom visual analogue scale weekly and the Functional Assessment of Chronic Illnesses Therapy-Fatigue questionnaire for fatigue. Patients were observed for 4 weeks following withdrawal of the drug. RESULTS One patient was unable to tolerate the study medication because of worsening pain after injection, and withdrew. Two showed clear benefit with reduction of symptoms overall, pain, bloating, distension, nausea and tiredness, with improved satisfaction and consistency of bowel actions and fatigue scores. Both reduced analgesic usage. The third had improved ileostomy output and had no episodes of severe bloating, but pain scores remained high. All three worsened after drug withdrawal and requested retreatment. Three experienced abdominal pains of moderate severity for 30-60 min consistently within 5 min of each injection. No other adverse events were experienced. CONCLUSIONS Methylnaltrexone has a positive impact on symptoms in women with NBS, although treatment does induce transient pain following its administration. Larger studies are required to examine its efficacy and longer term safety in this patient group.
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Affiliation(s)
- P R Gibson
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia.
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Lin DH, Wang CZ, Qin LF, Xie XX, Wang JT, Gu M, McEntee E, Yuan CS. Bioavailability of oral methylnaltrexone increases with a phosphatidylcholine-based formulation. Drug Dev Ind Pharm 2013; 40:186-91. [DOI: 10.3109/03639045.2012.753899] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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