Colin Campbell and Stephen Spencer (1) have presented elegantly the
dilemmas facing most UK paediatric units in their attempt to reduce the
average hours to 48 by 2009. Their solutions include employing senior
doctors as resident on call, the “hospital at night” solution , the
expansion of the advanced nurse practioner grade and rationalisation of
the number of units. They left out however the one so...
Colin Campbell and Stephen Spencer (1) have presented elegantly the
dilemmas facing most UK paediatric units in their attempt to reduce the
average hours to 48 by 2009. Their solutions include employing senior
doctors as resident on call, the “hospital at night” solution , the
expansion of the advanced nurse practioner grade and rationalisation of
the number of units. They left out however the one solution which would
avoid all the associated problems and that is to enlist the support of
representive bodies such as the Royal Colleges and BMA to back a call to
keep the current working time limit at 56-58 hours. Such a move would
preserve the status quo in terms of the provision of more comprehensive
training programmes, allow better patient care continuity and stop the
relentless demand for ever increasing numbers of junior doctors many of
whom have to be imported from countries who can ill afford to lose them.
We are told the new Health Secretary is a listener. We need to shout
loud.
Reference:
1.Campbell C, Spencer SA. The Implications of the Working Time
Directive: how can paediatrics survive? Arch Dis Child 2007; 92: 573-5.
The review on fractures in infancy is brilliant and very informative.
I would like to take this opportunity to stress the sensitive issue of
fractures due to osteopenia of prematurity that many a times needs
differentiating from child abuse.
Reports of osteopenia/rickets of prematurity are on the increase
because of improved survival rates of low birthweight infants.2 The
incidence of oste...
The review on fractures in infancy is brilliant and very informative.
I would like to take this opportunity to stress the sensitive issue of
fractures due to osteopenia of prematurity that many a times needs
differentiating from child abuse.
Reports of osteopenia/rickets of prematurity are on the increase
because of improved survival rates of low birthweight infants.2 The
incidence of osteopenia among infants born before 28 weeks of gestational
age are as high as 30%. 1 The contributory factors are prematurity, lack
of activity, chronic lung disease, use of diuretics, prolonged parenteral
nutrition and iatrogenic factors that are unavoidable in neonatal
intensive care. Iatrogenic injuries are frequently the result of
physiologic or anatomical response to proper and lifesaving treatment. The
most serious of these are found in the premature infant, who may suffer
chronic lung disease or, more seriously, brain damage.3
The diagnosis of osteopenia of prematurity remains difficult as there
is no screening test which is both sensitive and specific.5 Such infants
sometimes go undiagnosed of fractures from the neonatal unit and when they
come back with reasons like excessive crying and the x-rays show multiple
healing fractures, the differential of child abuse, unfortunately, tends
to take the top position.
Due to the obvious reasons and the sensitivity of the issue, clinicians
have shown concerns about the mistaken diagnosis of child abuse.4
I agree with the authors that the plain film radiography is not the
final arbiter of bone fragility in infancy; as with the other forms of
investigation discussed in the article, it is a part of the overall
approach to discriminating between a diagnosis of bone fragility and one
of non-accidental injury.Dual energy X-ray absorptiometry and
quantitative ultrasound has been employed by some neonatal units to
determine the mineral density of the bone but it is still not universal
due to the issues like ionising radiation and the difficulty to interpret
data.5
As a result, the clinicians, especially the junior doctors who happen
to be the first contact with the carers need to keep osteopenia of
prematurity high on their list of differentials especially when a NICU
graduate presents without an official diagnosis of it.
References
1. Kocsis I, Kis E, Szabó A, et al. Osteopenia of Prematurity. Orv
Hetil. 2005; 146:2491-7.
2. Caksen H, Oztürk A, Kurtoðlu S, et al .Reports of
osteopenia/rickets of prematurity are on the increase because of improved
survival rates of low birthweight infants. J Emerg Med 2002; 23:305-6.
3. Singleton EB. Intentional and unintentional abuse of infants and
children. Curr Probl Diagn Radiol 1986; 15:277-330
4. Blumenthal I. Osteogenesis imperfecta, non-accidental injury, and
temporary brittle bone disease. Arch Dis Child 1996; 74:91
5. McDevitt H, Ahmed SF. Quantitative ultrasound assessment of bone
health in the neonate. Neonatology 2007; 91:2-11.
As a close psychiatric colleague of paediatricians for over 25 years
I welcome this paper, but regret that the authors did not mention the
multidisciplinary team that makes general paediatrics so effective in a
disintegrating public service.
Close links with education, social work and mental health in
particular are essential and can only be achieved if these staff are on
site: hospital schoo...
As a close psychiatric colleague of paediatricians for over 25 years
I welcome this paper, but regret that the authors did not mention the
multidisciplinary team that makes general paediatrics so effective in a
disintegrating public service.
Close links with education, social work and mental health in
particular are essential and can only be achieved if these staff are on
site: hospital school, child and family social work and paediatric
liaison. The evidence base for mental health work in paediatrics is large,
yet our profile is not, which is a puzzle.
see http://mysite.wanadoo-
members.co.uk/djlino4/addingvalue.doc
May be if the general practitioners follow a rational policy in
starting an antibiotic, unnecessary use may be reduced significantly.
General practitioners need to be stressed on the point that there are
simple clinical markers that may help them differentiate a viral and
bacterial infection.
Viral infections are abundant, bacterial infections are occasional.
bacterial infections tend to local...
May be if the general practitioners follow a rational policy in
starting an antibiotic, unnecessary use may be reduced significantly.
General practitioners need to be stressed on the point that there are
simple clinical markers that may help them differentiate a viral and
bacterial infection.
Viral infections are abundant, bacterial infections are occasional.
bacterial infections tend to localise, usually do not come with bilateral
rhinorhea; are more toxic and have tendency for high fever, refusal to
feeds and focal signs.
Simple instructions that can be derived from above are:asymmetric
lymphnodes, white patch on throat, irregular/granular inflammation of
throat and toxic child can all be individually indicative of bacterail
infection.
Similarly, bilateral mild symmetric tonsillar enlargement without patch,
typical prodrome of malaise, rhinorhea, fever and transient rash on day 2,
alongwith uncomprmised feeding are more likely suggestive of a viral
infection.
Also, RSV causes typical course of illness- fever followed by
rhinitis cough and all settling in 5-7 days. Parainfluenza have affinity
for larynx, adenovirus has affinity for epiglottis, mycoplasma donot cause
common cold but have disproportionate distress. Influenza more often has
tachypnea in infants as pneumonia is more likely.
Sinusitis, otitis can be usually bacterial. Pharyngitis, Tosilitis
and laryngitis is more often viral. Bacterial tracheitis is common while
bacterial laryngitis is uncommon. Asymmetric lymph node enlargement is
usually bacterial and symmetric nodular enlargement is usually an evidence
of a viral infection.
Given a thought, as all this can be correct more than 90% percent of
times; general practitioners can very well utilise these facts to
judiciously decide the use of antibiotics.
Neena Modi writes a generally very good perspective on this important
issue. In particular, there is sensible comment in a call for reason now
that a sense of McCarthyism seems to surround any suggestion that breast
feeding can be difficult.
However, I think it often unwise to be reassured by mother and baby being
'well'. In my experience, the very fact that nothing seems to be wrong is
often a major co...
Neena Modi writes a generally very good perspective on this important
issue. In particular, there is sensible comment in a call for reason now
that a sense of McCarthyism seems to surround any suggestion that breast
feeding can be difficult.
However, I think it often unwise to be reassured by mother and baby being
'well'. In my experience, the very fact that nothing seems to be wrong is
often a major contributor to the tragedies that occur unless some kind of
screening process is implemented. These are typically firstborns, so
mothers may be happy with latching and sucking even when it is
ineffective. 'Wet nappies' from immature renal function may give
reassurance when they are not familiar with how heavy they should become.
More mature, professional women (as they often are) may feel they should
not ask for help with such a 'natural' process, even if exhausted after
surgery and blood loss. Perhaps ironically, 'acopia' in asking for help,
getting the baby weighed or changing to bottles will almost always allow
the short-term problem to be relatively easily addressed - local
experience suggests that even weight loss significantly above 10% is not a
major concern provided it is recognised.
Healthcare professionals reviewing progress may lack the skill, or perhaps
more crucially the time, to allow the ideal solution of early detection
and support - especially when these babies often do not appear
'dehydrated'. Unless far greater post-natal support can be given, I feel
this is one case where routine weighing of babies does have merit.
We read with great interest on the article “Randomised controlled trial of nasal Continuous Positive Airways Pressure (CPAP) in bronchiolitis” by Thia et al. 1 because the evidence of CPAP use in patients with acute bronchiolitis has not been very well established. 2 Nevertheless, we have adopted CPAP as standard management in bronchiolitis in our department for severe bronchiolitis for...
We read with great interest on the article “Randomised controlled trial of nasal Continuous Positive Airways Pressure (CPAP) in bronchiolitis” by Thia et al. 1 because the evidence of CPAP use in patients with acute bronchiolitis has not been very well established. 2 Nevertheless, we have adopted CPAP as standard management in bronchiolitis in our department for severe bronchiolitis for a few years and find CPAP very useful. However, we would like to make a few comments about Thia et al's study.
A cross-over trial in a dynamic disease like acute bronchiolitis with respiratory failure required considered justification. 3 Early CPAP use in such patients will definitely cause carry-over effect to the group of patients treated with CPAP first and they will likely to have a better outcome. 4 We used the reported data shown on table 2 of the original article and construct a diagram demonstrating the effect (Figure 1). As shown clearly on the graph, the response to CPAP depended on the timing of CPAP with earlier use better than late use. The current research design cannot answer the research question of Thia et al, i.e. to compare CPAP with ST in the management of bronchiolitis but addressed an alternative research question of early CPAP versus late CPAP in the management of bronchiolitis. The current research design could not compare the efficacy of CPAP to ST unless Thia et al provide some evidence to suggest the effect of first treatment was completely washed out before the second treatment. As seen in figure 2 of the original article, however, it was not likely to be the case. Furthermore, Thia et al. should report the CO2 reduction of the whole CPAP group, i.e. early and late use with that of the whole standard treatment group.
Reference:
Thia LP, McKenZie SA, Blyth TP, et al. Randomized controlled trial of nasal Continuous postive Airways Pressure (CPAP) in bronchiolitis. Arch Dis Child (In press)
Shah PS, Ohlsson A, Shah JP. Continuous negative extrathoracic pressure or continuous positive airway pressure for acute hypoxemic respiratory failure in children (The Cochrane Library 2007, Issue 2)
Sibbald B, Roberts C. Understanding controlled trials: Crossover trials. BMJ 1998; 316: 1719-1720.
Freeman PR. The performance of the two-stage analysis of two-treatment, two-period crossover trial. Stat Med 1989; 8: 1421-1432.
We read with interest the article “Severity of obstructive apnoea in children with Down syndrome who snore” by Fitzgerald et al. 1 Fitzgerald et al reported that 97% of Down syndrome (DS) children who snored had obstructive sleep apnea. In light of the limited access to sleep polysomnography (PSG) in children, 2 it would seem appropriate for DS children who snore together with tonsil hy...
We read with interest the article “Severity of obstructive apnoea in children with Down syndrome who snore” by Fitzgerald et al. 1 Fitzgerald et al reported that 97% of Down syndrome (DS) children who snored had obstructive sleep apnea. In light of the limited access to sleep polysomnography (PSG) in children, 2 it would seem appropriate for DS children who snore together with tonsil hypertrophy to be offered tonsillectomy and adenoidectomy without the need for PSG if the findings by Fitzgerald et al are confirmed by other studies. However, other existing studies not quoted by Fitzgerald et al reported a much lower prevalence.
The study by De Miguel-Diez et al 3 assessed 108 consecutive 1-18 years Down syndrome (DS) children and showed that the prevalence of PSG confirmed obstructive sleep apnea (OSA) in DS children was 54.6%. Another study by Shott et al 4 enrolled 56 younger DS children and showed that the prevalence of OSA was 57%. The case controlled study conducted in our department 5 showed that the prevalence of OSA in a group of 22 DS children recruited from the community was 59%. The above three studies showed a much lower prevalence than that demonstrated in Fitzgerald et al's study. It is probably due to the fact that the patients from Fitzgerald et al's series was enrolled from a sleep clinic and all DS patients enrolled were snorer. In our study,5 we showed that out of 13 DS children with OSA, only 5 of them were habitual snorer. Hence, we agree with Shott et al that routine baseline PSG should be provided to all DS children and not just snoring DS children as suggested by Fitzgerald et al. in light of the poor correlation between parental perception of symptoms during sleep and PSG abnormalities.
Another problem in the study by Fitzgerald et al1 was the inappropriate use of the normal value of arousal index of 5 for the whole study group aged from 0.2 to 19-year when the normal values of arousal index change with age, i.e. infants: 7-9 per hour, prepubertal children: 7+/-2 per hour, adolescents: 14+/-2 per hour and young adults: 16-18 per hour.6,7 The authors should also report the wake time after sleep onset (WASO) that may be related to daytime symptoms.
References:
Fitzgerald DA, Paul A, Richmond C. Severity of obstructive apnoea in children with Down syndrome who snore. Arch Dis Child 2007;92:423-5.
Ng DK, Kwok KL, Chow PY, Cheung MY. Diagnostic access for sleep apnea in Hong Kong. Am J Respir Crit Care Med 2004; 170: 196.
de Miguel-Diez J, Villa-Asensi JR, Alvarez-Sala JL. Prevalence of sleep-disordered breathing in children with Down syndrome: polygraphic findings in 108 children. Sleep 2003;26:1006-9.
Shott SR, Amin R, Chini B, Heubi C, Hotze S, Akers R. Obstructive sleep apnea: Should all children with Down syndrome be tested? Arch Otolaryngol Head Neck Surg 2006;132:432-6.
Ng DK, Hui HN, Chan CH, Kwok KL, Chow PY, Cheung JM, Leung SY. Obstructive sleep apnoea in children with Down syndrome. Singapore Med J 2006;47:774-9.
Traeger N, Schultz B, Pollock AN, Mason T, Marcus CL, Arens R. Polysomnographic values in children 2-9 years old: additional data and review of the literature. Pediatr Pulmonol 2005;40:22-30.
Marcus CL. Sleep-disordered breathing in children. Am J Respir Crit Care Med 2001; 164:16-30.
We read with interest the study by Luscombe and Owens(1)in which a
new age-based formula is proposed for estimating weight in paediatric
resuscitation. However, as the authors admit, the study findings are
limited to a specific UK population and may not apply elsewhere.
In contrast to the UK, where children's weights are increasing, in
Malawi undernutrition is a significant problem with 48% of...
We read with interest the study by Luscombe and Owens(1)in which a
new age-based formula is proposed for estimating weight in paediatric
resuscitation. However, as the authors admit, the study findings are
limited to a specific UK population and may not apply elsewhere.
In contrast to the UK, where children's weights are increasing, in
Malawi undernutrition is a significant problem with 48% of children under
5 years stunted, 22% underweight for age and 5% wasted (<2SD weight for
height/ length)(2). Here and in other developing countries, it seems
likely that an age-based formula developed in a well nourished population
will over-estimate the weight of many children. As 95% of Malawian
children are an appropriate length for their weight, measuring length may
offer a better guide to estimating weight.
To test this assumption we reviewed retrospectively data on children
aged 1-10 years admitted to the resuscitation area of the Queen Elizabeth
Central Hospital Accident and Emergency, Malawi over the last month. We
chose these children as they represent those most likely to receive
treatment based on an estimated weight. We identified 148 children, of
whom 100 had both an age (in months), and weight (measured during
admission, and recorded to the nearest 100g). Mean age was 30.3 months
(range 1-7 years). Mean weight was 11.1kg (range 6-26kg).
We then used the current formula (2x (age+4)) and the new formula
proposed by Luscombe et al (3x age +7) to assess their accuracy against
actual weight. The current formula over-estimated weight by a mean of
10.6% (range +28.5 to - 39% where a negative value reflects an over-
estimate). The proposed formula over-estimated weight by a mean of 17%
(range +21 to - 44%).
Most children requiring resuscitation were under 2 years. In older
children (>5 years, n=9), weight was overestimated to a greater extent
using the proposed formula, with a mean of 30.9%, compared to an over-
estimate of 14% using the current formula. This may reflect the cumulative
effect of age on stunting.
The formula recommended by APLS has affected resuscitation training
and treatment guidelines worldwide. For example 2x (age +4) has been used
to recommend drug doses and fluid volumes for different age groups in the
WHO guidelines for the integrated management of childhood illness (IMCI),
guidelines used widely in the developing world(3).
It should be remembered that in children with severe malnutrition, a
major cause of child mortality worldwide, over-resuscitation is dangerous,
potentially precipitating fluid over-load, cardiac failure and death.
We feel it is essential that should a new age-based formula be
adopted, especially by such an influential group as APLS, it be made clear
that this formula only applies to a UK population and is not appropriate in many other settings.
Where stunting is common, the length of a child may better reflect
their weight and we have evaluated a triage length tape previously(4). The
length tape has the advantage that doses can be marked on it, reducing
calculation error. However for any tool to be useful it needs to be
readily available and a simple age-based equation meets this requirement
well. WHO may wish to determine an appropriate, simple and validated
equation for use in low resource settings.
References:
1.Luscombe M, Owens B. Weight estimation in resuscitation: is the
current formula still valid? Arch.Dis.Child. 2007;92;412-415.
2.National Statistics Office. Malawi Demographic and Health Survey
2004, NSO and ORC Macro, Malawi, 2005.
3.Management of the child with a serious infection or severe
malnutrition: guidelines for first-referral level in developing countries.
WHO Geneva, 2000.
4.Molyneux E, Brogan R, Mitchell G, Gove S. Children's Weights: guess
or measure by tape? Lancet 1999; 354: 1616.
I read with great interest the article by Clark et al1 which
described the spectrum of clinical features and management of community
acquired paediatric pneumonia in the UK. The patients were children (0-15
years) with radiologically-proven pneumonia who presented to hospitals in
the North East of England between August 2001 and July 2002. Children
were excluded if there was a clinical diagnosis of br...
I read with great interest the article by Clark et al1 which
described the spectrum of clinical features and management of community
acquired paediatric pneumonia in the UK. The patients were children (0-15
years) with radiologically-proven pneumonia who presented to hospitals in
the North East of England between August 2001 and July 2002. Children
were excluded if there was a clinical diagnosis of bronchiolitis, if they
had been in hospital in the preceding 3 weeks or if their main place of
residence was not within the Region. I shared the authors’ surprise at
the admission rate (89%) which seems very high in comparison to practice
in the hospital where I work. Local audit using the same inclusion &
exclusion criteria as above identified 47 children with community acquired
pneumonia presenting over the 5 month period 1st January – 31st May 2007.
All of the children were assessed in our Paediatric Short Stay Assessment
Unit and the decision about whether to admit or discharge was taken after
a period of observation (median length 4.8 hours). Just 57% (n=27) were
admitted to hospital; the rest (n=20) were discharged home with oral
antibiotics and 6 of these children had reviews arranged for 3 - 7 days
later. All discharged children were given “open access” to the Unit
(their parents could call the Unit directly at any time for advice or to
request review) but only 1 family used this service. These data lend
support to previous evidence2 that short stay facilities reduce paediatric
admission rates and, since we all appreciate that children are best
managed at home whenever possible, I would be very interested to learn
about the availability of short stay facilities in the Paediatric Units
included in Clark’s review.
Competing interests: None declared
References:
1. Clark JE, Hammal D, Spencer D, et al. Children with pneumonia: how
do they present and how are they managed? Arch Dis Child 2007;92:394-398.
2. MacLeod C, McElroy G, O’Loan D, et al. Ambulatory paediatrics:
does it work? Ir Med J 2002;95(2):41-44.
Philips et al (1) confirm findings which we presented at the York
Spring meeting in 2005 (2). What perhaps needs highlighting is the
increasing burden of work taken on by shared care centres in managing
patients with febrile neutropenia. It is this group who may benefit more
greatly from the development of a standardized febrile neutropenia
protocol. Working in a shared care oncology centre the need fo...
Philips et al (1) confirm findings which we presented at the York
Spring meeting in 2005 (2). What perhaps needs highlighting is the
increasing burden of work taken on by shared care centres in managing
patients with febrile neutropenia. It is this group who may benefit more
greatly from the development of a standardized febrile neutropenia
protocol. Working in a shared care oncology centre the need for
standardisation to ensure safe practice in the delivery of supportive care
as well as chemotherapy protocols is paramount. This is also in keeping
with the IOG (Improving Outcomes Group) recommendation to provide safe
care as locally as possible (3). Agreed standards between CCLG (Children’s
Cancer and Leukaemia Group), formerly known as UKCCSG, centres, would
allow for standardization of care between the many shared care centres
ensuring continuity of care. At UHNS (University Hospital North
Staffordshire) we share care with two separate CCLG centres with differing
febrile neutropenia protocols, we have therefore developed our own
guideline which may or may not be optimal.
We look forward to putting into practice a standardized national
approach to febrile neutropenia and other supportive measures in the near
future.
References:
1. Philips B, Selwood K, Lane SM, Skinner R, Gibson F, Chisholm J.
Variation in policies for the management of febrile neutropenia in United
Kingdom Children’s Cancer Study Group centres. Arch Dis Child 2007; 92:
495-498.
2. Humphrey S, Parke S, McMaster P. Febrile Neutropenia Management in the
UK? Arch Dis Child 2005; 90 (suppl II) A54. G132.
3. National Institute for Health and Clinical Excellence. Improving
Outcomes in Children and Young People with Cancer. NICE 2005
Dear Editor,
Colin Campbell and Stephen Spencer (1) have presented elegantly the dilemmas facing most UK paediatric units in their attempt to reduce the average hours to 48 by 2009. Their solutions include employing senior doctors as resident on call, the “hospital at night” solution , the expansion of the advanced nurse practioner grade and rationalisation of the number of units. They left out however the one so...
Dear Editor,
The review on fractures in infancy is brilliant and very informative. I would like to take this opportunity to stress the sensitive issue of fractures due to osteopenia of prematurity that many a times needs differentiating from child abuse.
Reports of osteopenia/rickets of prematurity are on the increase because of improved survival rates of low birthweight infants.2 The incidence of oste...
Dear Editor,
As a close psychiatric colleague of paediatricians for over 25 years I welcome this paper, but regret that the authors did not mention the multidisciplinary team that makes general paediatrics so effective in a disintegrating public service.
Close links with education, social work and mental health in particular are essential and can only be achieved if these staff are on site: hospital schoo...
Dear Editor,
May be if the general practitioners follow a rational policy in starting an antibiotic, unnecessary use may be reduced significantly. General practitioners need to be stressed on the point that there are simple clinical markers that may help them differentiate a viral and bacterial infection.
Viral infections are abundant, bacterial infections are occasional. bacterial infections tend to local...
Dear Editor,
Neena Modi writes a generally very good perspective on this important issue. In particular, there is sensible comment in a call for reason now that a sense of McCarthyism seems to surround any suggestion that breast feeding can be difficult. However, I think it often unwise to be reassured by mother and baby being 'well'. In my experience, the very fact that nothing seems to be wrong is often a major co...
Dear Editor,
We read with great interest on the article “Randomised controlled trial of nasal Continuous Positive Airways Pressure (CPAP) in bronchiolitis” by Thia et al. 1 because the evidence of CPAP use in patients with acute bronchiolitis has not been very well established. 2 Nevertheless, we have adopted CPAP as standard management in bronchiolitis in our department for severe bronchiolitis for...
Dear Editor,
We read with interest the article “Severity of obstructive apnoea in children with Down syndrome who snore” by Fitzgerald et al. 1 Fitzgerald et al reported that 97% of Down syndrome (DS) children who snored had obstructive sleep apnea. In light of the limited access to sleep polysomnography (PSG) in children, 2 it would seem appropriate for DS children who snore together with tonsil hy...
Dear Editor,
We read with interest the study by Luscombe and Owens(1)in which a new age-based formula is proposed for estimating weight in paediatric resuscitation. However, as the authors admit, the study findings are limited to a specific UK population and may not apply elsewhere.
In contrast to the UK, where children's weights are increasing, in Malawi undernutrition is a significant problem with 48% of...
Dear Editor,
I read with great interest the article by Clark et al1 which described the spectrum of clinical features and management of community acquired paediatric pneumonia in the UK. The patients were children (0-15 years) with radiologically-proven pneumonia who presented to hospitals in the North East of England between August 2001 and July 2002. Children were excluded if there was a clinical diagnosis of br...
Dear Editor,
Philips et al (1) confirm findings which we presented at the York Spring meeting in 2005 (2). What perhaps needs highlighting is the increasing burden of work taken on by shared care centres in managing patients with febrile neutropenia. It is this group who may benefit more greatly from the development of a standardized febrile neutropenia protocol. Working in a shared care oncology centre the need fo...
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