smart therapy
TRANSCRIPT
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Presented By :
Dr. Md. Khairul Hassan Jessy Associate Professor
Respiratory MedicineNIDCH, Dhaka
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Objective
• To focus on –
management of persistent
asthma
using a single inhaler both for
maintenance & additional rescue
use
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•Asthma is a global concern
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Facts About Asthma
• Asthma occurs in all countries
regardless of the level of
development
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Facts About Asthma
• It is one of the major
non-communicable diseases
affecting the airways
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Facts about Asthma
• It occurs in people of all ages
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Facts About Asthma
•Asthma is often under-
diagnosed and under-treated,
creating a substantial burden
to individuals and families
and possibly restricting
individuals’ activities for a
lifetime.
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Asthma: limits daily-life activities
0
20
40
% o
f pa
tien
ts
60
Social activities
Career Choice
Housekeeping
Lifestyle
Normal Physical Activity
SleepingSports
Asia Pacific Europe US
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Facts About Asthma
• Despite effective pharmacological
options for treating asthma most
patients fail to achieve
good control
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Patients Currently Achieving Control
Not Well-ControlledWell-Controlled
Only 5% of patients
achieve asthma control
Rabe et al. Eur Respir J, 2000
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Facts About Asthma
Non adherence is common
with
Overreliance on short acting β2
agonist and
Underuse of inhaled corticosteroids
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Short acting β – 2 agonist
Inhaled corticosteroid
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Deaths due to asthma are
uncommon but are of
serious concern because
many of them are
preventable
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Facts About Asthma
•Most asthma related deaths occur
in low and lower middle income
countries
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Asthma related mortality is
higher among the poor
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Asthma related mortality is higher
among the poor
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Facts About Asthma
• Through appropriate treatment such as using
inhaled corticosteroids to ease bronchial inflammation, the number of asthma-related
deaths can be reduced
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Fluticasone Propionate( ICS )
Use of ICS can reduce asthma related mortality
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Global Burden of Asthma
• Some 334 million people currently
suffer from asthma
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Global Burden of Asthma
• It affects 1-18 % of the population in different countries
& the prevalence is rising
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Global Burden of Asthma
• 14% of the world’s children
experience asthma symptoms
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Situation in Bangladesh
• About 7 million people
(5.2% of the population) are suffering from asthma
• 4 million of them are in 1-15 years age group
(NAPS, 1999]
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Situation in Bangladesh
• It is very likely that the
number of asthma patients
has increased many times
in last few years
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Situation in Bangladesh
• >90% do not get modern treatment
Source: First National Asthma Prevalence Study (NAPS, 1999]
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• Bronchial asthma
is a chronic inflammatory disease of
the airways that is characterized by
respiratory symptoms associated
with
variable airflow obstruction, airway
hyper-responsiveness, and
airway remodeling
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History
• Asthma was first recognized in
ancient Egypt & treatment was inhalation of frankincense
Source : Wikipedia
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History
Asthma was first recognized & named by Hippocrates
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100 years of asthma treatment
AdrenalineOral steroidsTheophylline
Inhaled β2-agonistsSodium cromoglycate
Inhaled anticholinergicInhaled steroids
Long-actingβ2-agonists
Leukotrieneinhibitors
Anti-IgE
1900 1960 1970 1980 1990 2000...
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History
In the last few years there In the last few years there
have been remarkable have been remarkable
progress and outstanding progress and outstanding
improvement in the improvement in the
management of Bronchial management of Bronchial
AsthmaAsthma
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History
•Newer combinations in many
dosage forms are evolving
to achieve optimal control
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History
• Combination therapy is now
considered to be an
excellent choice for
persistent asthma
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Causes
•The fundamental causes are
not completely understood
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Causes
• The strongest risk factors are a
combination of
genetic predisposition
with environmental exposure to
allergens/asthma triggers
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Pathophysiology
• There are 3 fundamental
changes associated with
inflammation in asthma
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Pathophysiology
• These are
▫ Airway hyperresponsiveness
▫ Variable airflow obstruction
( usually reversible )
▫ Airway remodeling
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Pathophysiology
It is the most important fundamental change in asthma
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Asthma Symptoms
• Coughing
•Wheezing
• Chest
tightness
• Shortness of
breath
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Symptoms
• Symptoms may occur several times in a day or week in
affected individuals.
• For some people the symptoms become worse
during physical activity or at night.
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Examination
• BP examination & examination of
both lungs fields are 2 important
steps to exclude Bronchial from
Cardiac asthma
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EPA Indoor Environments Division, Jan 2001, Slide 60
of asthmaTwo parts
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Lung function assessment
The important lung function
tests are :
• forced expiratory volume in 1
second (FEV1) and peak
expiratory flow (PEF)
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Lung Function Assessment
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Classification
• Asthma is classified into four
groups
~ Intermittent asthma
~ Persistent asthma
~ Acute exacerbation
~ Special variants
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Treatment
It is not a curable diseaseIt is not a curable disease
But to a large extent But to a large extent
controllable controllable
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With With
education, caution & education, caution &
medication medication most cases of asthma can be most cases of asthma can be
effectively managedeffectively managed
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Treatment
• Long term goals of asthma
management –▫ to achieve good control of symptoms
& maintain normal activity levels
▫ to minimize future risk of
exacerbation
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Treatment
•Asthma management is flexible
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Treatment
The drugs used in asthma
should be given in a stepwise
fashion
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Asthma Medications
Medicine used to treat
asthma are basically three
types-
• Relievers
• Preventers
• Protectors
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Asthma Medications
Drugs are available in the form
of
› Inhaler
›Oral route
›Parentaral route
›Suppository
›Nebulizer solution
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Asthma Medications
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Asthma Medications
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Treatment
• The guidelines for the
management of
persistent asthma in adults
recommend
an inhaled corticosteroid
(ICS)
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Treatment
• ICS are the most effective
treatment for inflammatory
component of asthma
(disease preventers)
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• ICS targets the inflammation in asthma
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Treatment
• Most studies show that
early treatment with ICS
prevents
decline in lung function
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Treatment
• When asthma is
inadequately controlled
with a moderate dose of ICS –
combination therapy
is recommended
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Treatment
• Several studies have shown that
combination of LABA to ICS is
more effective than increasing
the dose of ICS alone
Source : GINA
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Treatment
• The combinations now
available for clinical use-
budesonide & formeterol
fluticasone & salmeterol
beclomethasone & formeterol
Widely Used
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Treatment
•Most recent ICS / LABA
combination is Mometasone
furoate combined with
Formoterol
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Treatment
• Combination medications are
available in MDI & DPI forms
• Comparison of different
medication delivery device
has shown similar results
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Long Acting β2 Agonist ( LABA )
• Two drugs are in common clinical use
- Salmeterol
- Formoterol
• Action lasts for up to 12 hours
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Mechanism of Action
• β-2 agonists relax the contracted airway smooth
muscle through a direct action on β-2
adreno - receptors
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LABA
• Formoterol has a rapid onset of action ( 1- 2 min ) and can be used as a reliever
• Salmeterol has a delayed onset of action and cannot be used as a reliever
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Salmeterol
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LABA : Speed of Action
• Fast Onset, Long Duration
Inhaled Formoterol
• Slow Onset, Long Duration
Inhaled Salmeterol
Oral Bambuterol
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Onset of Action: β2-Agonists
90
0 5 10 15 20 25
Placebo
Salmeterol Diskhaler50 µg
Albuterol Turbuhaler50 µg
FormoterolTurbuhaler 9 µg
▲ FEV (%)
Comparisons 3 min after inhalation of bronchodilator *
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LABA
• An important observation of
many large scale trials is that
Inhaled Formoterol has a rapid
onset of action similar to that
of Salbutamol
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LABA
• Long acting β 2 agonists -
Salmeterol & formoterol
should not be used as
monotherapy
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Caution
• LABA monotherapy may increase the risk of asthma related death
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SMART
• The acronym SMART stands
for
Single /Symbicort Maintenance
And
Reliever Therapy
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SMART
• 2 active ingredients are delivered via a single inhaler
• Budesonide – an anti-inflammatory corticosteroid
• Formoterol - a rapid acting & long
lasting β-2 agonist,bronchodilator
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Budesonide & Formeterol
Regular Maintenance with Bud
Long Acting Bronchodilatation with Form
Rapid anti-inflammatory effect with Bud
Rapid Bronchodilatation with Form
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SMART
• In 2001 , Astrazeneca
launched a new product
Symbicort turbuhaler containing
2 active ingredients
( budesonide & formoterol ) via a
single inhaler
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SMART
• A novel treatment approach
known as Single Maintenance And
Reliever Therapy ( SMART ) was
focused
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SMART
• Due to its unique properties Formoterol -budesonide is
currently the only ICS/ LABA combination that is approved to
be used as maintenance & relief in one inhaler
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®
Symbicort and Asthma – Mechanism of Action.mht
Onset of action of Budesonide + Formoterol is similar to Salbutamol
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Budesonide + Formoterol has better efficacy than Salmeterol + Fluticasone
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Budesonide + Formoterol compared with fixed dose
Salmeterol + Fluticasone
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Budesonide + Formoterol
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Treatment
• The traditional approach is to
prescribe an ICS/LABA to achieve
control and additional SABA for
rescue use so most patients will
use at least 2 inhalers
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Treatment
• In SMART model the patient is
provided with 1 ICS/LABA inhaler
both for maintenance and
additional rescue use in place of
SABA
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•With SMART there is no need for a separate SABA
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SMART
•Here the drugs are used to
provide a stable dosing regime (FD)
to achieve day to day control
but
• The dose can be increased during
worsening of symptoms ( AMD )
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SMART
• The maintenance dose is
adjustable but a minimum of 2
doses/day should be
administered as one dose
twice daily
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SMART
• Dose is to be individualized
and adjusted according to
severity
•When control has been
achieved the dose should
be titrated to the lowest
effective dose
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08/12/17
113
Dose is increased with asthma worsening. When control is maintained the dose is titrated to the lowest effective
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Key to Success
•Good communication between
doctor and patient is an integral
part of management using
SMART
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Limitations
• Patients should be warned about
maximum recommended dose ( up
to 8 puffs per day )
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Limitations
• The issue of safety in
children on long term use
of SMART is yet to be
resolved
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Limitations
• This strategy is not suitable for
those who find it difficult to
recognize worsening of symptoms
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Benefits
•Managing asthma in SMART
fashion is a safe and simplified
approach
• Provides rapid relief of symptoms
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Benefits
• Reduces the future risk of
exacerbations
• A lower dose of ICS is needed
compared to ICS therapy alone
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Benefits
• SMART reduces exacerbations
in terms of rate, severity & time to first exacerbation
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Benefits
•Reduces the risk of emergency room / hospital visits
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Benefits
• Reduces the number of visits to a doctor
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Benefits
• Patient can increase the dose during worsening of symptoms
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Benefits
• SMART strategy is cost effective
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Benefits
• Offering good control of asthma improves quality of
life….
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SMART
• This treatment approach
has been approved by the
GINA guideline as an
effective treatment strategy
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SMART
• This treatment strategy is
given an evidence A rating
by GINA
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Evidence A
means evidence from well
designed RCTs taking
substantial number of
studies involving substantial
number of participants
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GINA
• GINA is one of the founding participants of WHO’s Global Alliance against Respiratory Diseases (GARD)
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SMART/caution
• SMART is NOT indicated for
the relief of acute
bronchospasm
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SMART/caution
• SMART should not be
initiated during rapidly
deteriorating or potentially
life-threatening episodes of
asthma
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Safety in Pregnancy
• There have been limited studies on terratogenic risk
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Safety in Pregnancy
• LABA
Formoterol – pregnancy
category C
• ICS
Budesonide - pregnancy
category B
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Contraindications
•Hypersensitivity to
budesonide,
formoterol or
inhaled lactose
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Hypersensitivity
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Take home messages
• Asthma is a chronic
inflammatory disorder
affecting the airways
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Take home messages
• Long term asthma control
using ICS ( alone/ in
combination with LABA ) are
the corner stone of therapy
in persistent asthma
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Take home messages
• Combination of
Budesonide & Formoterol
using
AMD via a single inhaler ( SMART ) now appears to be
an excellent approach
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Take Home Messages
• It offers a simple , effective &
safe approach to persistent
asthma management for
physician & patient
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Conclusion
• Although asthma cannot be cured,
appropriate management can
control the disease and enable
people to enjoy a good quality of
life
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Conclusion
•SMART is one such option
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Conclusion
• It represents a new & unique
way of treating patients with
moderate to severe asthma
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Conclusion
•We are now trying to provide
the best possible effort to
reduce the burden of asthma
related morbidity and
mortality in BD
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NIDCH, Bangladesh
Providing services to asthmatic patients
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A name of
NIDCH
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Conclusion
• But
UNIVERSAL HEALTH COVERAGE
(UHC)
continues to be an important
issue
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Conclusion
•UHC means that all
individuals & communities
receive the health services
they need without suffering
financial hardship
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Conclusion
•Political commitment ,
momentum & action plan are essential to reach the goal
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Conclusion
• Like Global Asthma Network,
we are also waiting for a
world where no one suffers
from asthma
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To myself I am only a child playing on the beach, while vast oceans of truth lie
undiscovered before me
- Isaac Newton
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