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Prevalence and features of delirium in older patients admitted to rehabilitation facilities: a multicenter study. Aging Clin Exp Res 2022; 34:1827-1835. [PMID: 35396698 DOI: 10.1007/s40520-022-02099-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 02/16/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Delirium is thought to be common across various settings of care; however, still little research has been conducted in rehabilitation. AIM We investigated the prevalence of delirium, its features and motor subtypes in older patients admitted to rehabilitation facilities during the three editions of the "Delirium Day project". METHODS We conducted a cross-sectional study in which 1237 older patients (age ≥ 65 years old) admitted to 50 Italian rehabilitation wards during the three editions of the "Delirium Day project" (2015 to 2017) were included. Delirium was evaluated through the 4AT and its motor subtype with the Delirium Motor Subtype Scale. RESULTS Delirium was detected in 226 patients (18%), and the most recurrent motor subtype was mixed (37%), followed by hypoactive (26%), hyperactive (21%) and non-motor one (16%). In a multivariate Poisson regression model with robust variance, factors associated with delirium were: disability in basic (PR 1.48, 95%CI: 1.17-1.9, p value 0.001) and instrumental activities of daily living (PR 1.58, 95%CI: 1.08-2.32, p value 0.018), dementia (PR 2.10, 95%CI: 1.62-2.73, p value < 0.0001), typical antipsychotics (PR 1.47, 95%CI: 1.10-1.95, p value 0.008), antidepressants other than selective serotonin reuptake inhibitors (PR 1.3, 95%CI: 1.02-1.66, p value 0.035), and physical restraints (PR 2.37, 95%CI: 1.68-3.36, p value < 0.0001). CONCLUSION This multicenter study reports that 2 out 10 patients admitted to rehabilitations had delirium on the index day. Mixed delirium was the most prevalent subtype. Delirium was associated with unmodifiable (dementia, disability) and modifiable (physical restraints, medications) factors. Identification of these factors should prompt specific interventions aimed to prevent or mitigate delirium.
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The association between low skeletal muscle mass and delirium: results from the nationwide multi-centre Italian Delirium Day 2017. Aging Clin Exp Res 2022; 34:349-357. [PMID: 34417734 PMCID: PMC8847195 DOI: 10.1007/s40520-021-01950-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 07/31/2021] [Indexed: 01/22/2023]
Abstract
Introduction Delirium and sarcopenia are common, although underdiagnosed, geriatric
syndromes. Several pathological mechanisms can link delirium and low skeletal muscle mass, but few studies have investigated their association. We aimed to investigate (1) the association between delirium and low skeletal muscle mass and (2) the possible role of calf circumference mass in finding cases with delirium. Methods The analyses were conducted employing the cross-sectional “Delirium Day” initiative, on patient 65 years and older admitted to acute hospital medical wards, emergency departments, rehabilitation wards, nursing homes and hospices in Italy in 2017. Delirium was diagnosed as a 4 + score at the 4-AT scale. Low skeletal muscle mass was operationally defined as calf circumference ≤ 34 cm in males and ≤ 33 cm in females. Logistic regression models were used to investigate the association between low skeletal muscle mass and delirium. The discriminative ability of calf circumference was evaluated using non-parametric ROC analyses. Results A sample of 1675 patients was analyzed. In total, 73.6% of participants had low skeletal muscle mass and 24.1% exhibited delirium. Low skeletal muscle mass and delirium showed an independent association (OR: 1.50; 95% CI 1.09–2.08). In the subsample of patients without a diagnosis of dementia, the inclusion of calf circumference in a model based on age and sex significantly improved its discriminative accuracy [area under the curve (AUC) 0.69 vs 0.57, p < 0.001]. Discussion and conclusion Low muscle mass is independently associated with delirium. In patients without a previous diagnosis of dementia, calf circumference may help to better identify those who develop delirium. Supplementary Information The online version contains supplementary material available at 10.1007/s40520-021-01950-8.
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[A three-months follow up of a randomized controlled trial of Assisted Walking Program for in-hospital geriatric patients]. ASSISTENZA INFERMIERISTICA E RICERCA : AIR 2022; 41:23-32. [PMID: 35411880 DOI: 10.1702/3785.37702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
UNLABELLED . A three-months follow up of a randomized controlled trial of Assisted Walking Program for in-hospital geriatric patients. INTRODUCTION Functional decline is common among older hospitalized patients. In fact, low mobility and bed rest during hospitalization have been considered as predictable causes of independent ambulation decline in older hospitalized patients. PRIMARY ENDPOINT the older patients' walking ability change, compared with usual care, from hospital pre-admission/admission to discharge and 90 days follow-up, assessed with the Braden Activity subscale. The secondary end point was the occurrence of re-hospitalization and mortality. METHODS A 90-days follow-up randomized controlled trial, open labeled was conducted in a geriatric ward. RESULTS A total of 307 hospitalized patients (>65 years) were included. The intervention group received an Individualized Assisted Walking Program (IAWP), which significantly improved walking ability at discharge (p<.001) and 90-day follow-up (p=0.009), compared to the control group, which received the usual care. There were no significant differences in terms of mortality and re-hospitalizations. CONCLUSIONS An individualized assisted walking program improves walking abilitiy during hospitalization and over time. For this, a nurse staffing and workload reorganization, a multidisciplinary approach, and an early nurses' planning, could be relevant factors in influencing successfully the older patients' healthcare.
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Prognostic Value of Stress Hyperglycemia in Patients Admitted to Medical/Geriatric Departments for Acute Medical Illness. Diabetes Ther 2022; 13:145-159. [PMID: 34859364 PMCID: PMC8638797 DOI: 10.1007/s13300-021-01183-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 11/17/2021] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Hyperglycemia is common in patients admitted to Italian medical/geriatric units and is associated with a poorer outcome. We tested the significance of diabetes and stress-induced hyperglycemia in clinical outcome. MATERIALS AND METHODS Three hundred seventy-eight consecutive patients with hyperglycemia at entry (≥ 126 mg/dl) (206 without known diabetes) were included, with a wide range of underlying diseases requiring hospital admission and independent of the presence of diabetes. Relative hyperglycemia was calculated as admission glucose divided by average glucose, estimated based of glycosylated hemoglobin. Values ≥ 1.20 were considered indicative of stress hyperglycemia (SHR). The association of SHR with outcome variables (all-cause complications, infections, non-infectious events, deaths) was tested by logistic regression analysis, adjusted for sex, BMI, age-adjusted comorbidities (Charlson index) and known diabetes. RESULTS During hospital stay, one or more events were registered in 96 patients (25.4%); 44 patients died in hospital, and fatality rate was borderline higher in patients without diabetes (14.6% vs. 8.1% in diabetes; P = 0.052) and nearly three times higher in patients with stress hyperglycemia (15.0%) vs. those with SHR < 1.2 (P = 0.005). Stress hyperglycemia-more common in the absence of diabetes (71% vs. 58%)-and age were the only independent prognostic factors for death. At multivariable analysis, the risks of death (OR 4.31, 95% CI 1.25-14.81), of all complications (OR 5.90, 95% CI 2.22-15.71) and of newly developed systemic infections (OR 5.67, 95% CI 1.61-19.92) were associated with stress hyperglycemia in subjects without diabetes, as was the risk in non-insulin-treated cases (OR 4.02, 95% CI 1.16-13.92; OR 5.47, 95% CI 2.21-13.52; OR 5.15, 95% CI 1.70-15.62, respectively). CONCLUSION The study confirms the prognostic value of stress-related hyperglycemia in patients requiring hospital admission to a geriatric/medical unit for a variety of acute medical conditions, contributing to adverse outcomes not limited to events commonly associated with hyperglycemia (e.g., infections).
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Clinical Role of Lung Ultrasound for the Diagnosis and Prognosis of Coronavirus Disease Pneumonia in Elderly Patients: A Pivotal Study. Gerontology 2020; 67:78-86. [PMID: 33271558 PMCID: PMC7801997 DOI: 10.1159/000512209] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 10/10/2020] [Indexed: 11/19/2022] Open
Abstract
Background Lung ultrasound (LUS) showed a promising role in the diagnosis and monitoring of patients hospitalized for novel coronavirus disease (COVID-19). However, no data are available on its role in elderly patients. Aims The aim of this study was to evaluate the diagnostic and prognostic role of LUS in elderly patients hospitalized for severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) pneumonia. Methods Consecutive elderly patients (age >65 years) hospitalized for COVID-19 were enrolled. Demographics, laboratory, comorbidity, and the clinical features of the patients were collected. All patients underwent LUS on admission to the ward. LUS characteristics have been analyzed. Uni- and multivariate analyses to evaluate predictors for in-hospital death were performed. Results Thirty-seven hospitalized elderly patients (19 men) with a diagnosis of SARS-CoV-2 infection were consecutively enrolled. The median age was 82 years (interquartile range 74.5–93.5). Ultrasound alterations were found in all patients enrolled; inhomogeneous interstitial syndrome with spared areas (91.9%) and pleural alterations (100%) were the most frequent findings. At univariate analysis, LUS score (hazard ratio [HR] 1.168, 95% CI 1.049–1.301) and pleural effusions (HR 3.995, 95% CI 1.056–15.110) were associated with in-hospital death. At multivariate analysis, only LUS score (HR 1.168, 95% CI 1.049–1.301) was independelty associated with in-hospital death. The LUS score's best cutoff for distinguishing patients experiencing in-hospital death was 17 (at multivariate analysis LUS score ≥17, HR 4.827, 95% CI 1.452–16.040). In-hospital death was significantly different according to the LUS score cutoff of 17 (p = 0.0046). Conclusion LUS could play a role in the diagnosis and prognosis in elderly patients hospitalized for SARS-CoV-2 infection.
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Assisted Walking Program on Walking Ability in In-Hospital Geriatric Patients: A Randomized Trial. J Am Geriatr Soc 2020; 69:637-643. [PMID: 33184855 DOI: 10.1111/jgs.16922] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 09/14/2020] [Accepted: 10/04/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The main aim of this study was to evaluate if an individualized assisted walking program (IAWP) for hospitalized older patients could improve walking ability compared with usual geriatric care and rehabilitation. DESIGN A randomized controlled trial with an active control group, open labeled with parallel assignment was conducted between October 2018 and January 2020. SETTING Geriatric ward. PARTICIPANTS A total of 387 hospitalized patients (≥65 years) were randomly assigned to an intervention or control (usual-care) group. INTERVENTION The control group received usual hospital care. The intervention group received also an IAWP. MEASUREMENTS The primary endpoint was change in walking ability from hospital admission (considering both current and pre-admission status) to discharge, as assessed with the Braden Activity subscale measures. The secondary endpoint was the occurrence of in-hospital adverse events, such as complications of mobility, pressure ulcers, falls, pain and mortality, and the length of hospital stay. Intention-to-treat and per-protocol analyses were performed. RESULTS Baseline characteristics were similar between intervention and control groups. The intervention group, relative to the control group, had significantly improved walking ability at discharge (P < .001). There were no statistically significant differences between the groups in terms of in-hospital adverse events. No adverse effects were detected. CONCLUSION In in-hospital patients aged 65 and older, an IAWP improves walking ability at discharge.
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How hospital geriatric care is changing during COVID-19 pandemic: drawbacks and possible solutions. GERIATRIC CARE 2020. [DOI: 10.4081/gc.2020.9043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Since the outbreak of coronavirus disease- 19 (COVID-19) pandemic, geriatric population has been the most affected due to the peculiarities of the disease in terms of contagiousness and severity. Major changes have been implemented in healthcare structures and facilities worldwide in order to accomplish the necessity to host and isolate infected patients. Simultaneously, many critical issues have emerged concerning medical and nursing assistance to elderly patients, due to the new arrangement of wards and innovative work tools. Acute Geriatric Units dedicated to COVID-19 have been asked to put giant efforts in adapting to new care models in mobility, communication, feeding, basic assistance and caregivers’ involvement. The purpose of this dissertation is to highlight the role of Geriatricians as proactive contributors of new approaches to elderly patients in times of COVID-19, in order to develop a further-thinking working methodology.
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Syphilis as osteomyelitis of the fifth metatarsal of the left foot: the great imitator hits once again. Int J Infect Dis 2020; 96:10-11. [PMID: 32289561 DOI: 10.1016/j.ijid.2020.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/04/2020] [Accepted: 04/06/2020] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION We report an unusual case of osteomyelitis of the left foot due to syphilitic bone involvement. CASE PRESENTATION A 73-year-old man came to our attention with a four-month history of fever and a hypertrophic ulceration of the fifth metatarsal of the left foot. He had a history of syphilis treated years before. The CT scan showed an evident osteolytic area of the metatarsal phalangeal joint of the fifth left toe. The serological tests demonstrated a syphilitic reinfection. On suspicion of a bone localization of syphilis, an US-guided bone biopsy was performed. The histological examination with silver impregnation confirmed the diagnosis. The patient was treated with the traditional treatment of syphilis using penicillin, obtaining the complete resolution of the radiological and cutaneous alterations. CONCLUSIONS The aim of this work is to sensitize clinicians to suspect syphilis in case of osteolytic lesions in patients with a history of this disease.
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Understanding Factors Associated With Psychomotor Subtypes of Delirium in Older Inpatients With Dementia. J Am Med Dir Assoc 2020; 21:486-492.e7. [DOI: 10.1016/j.jamda.2020.02.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 02/15/2020] [Accepted: 02/19/2020] [Indexed: 12/12/2022]
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P2542Adherence to the 2016–2018 ESC guidelines for stroke prevention in atrial fibrillation: an Italian field practice in a cohort of geriatric patients. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The 2016 and 2018 ESC guidelines for stroke prevention in atrial fibrillation (AF) recommend the use of non-vitamin K antagonist oral anticoagulants (NOACs) in all AF patients except for the EHRA type 1, for which remains the indication to vitamin K antagonist oral anticoagulants (VKAs).
Purpose
To evaluate the adherence to the ESC guidelines in the management of anticoagulant therapy (OAC) in the prevention of cardioembolism in geriatric (age ≥65) AF patients at 3 medical-geriatric inpatient wards of the Sant'Orsola Hospital in Bologna (Emilia Romagna region, Italy).
Methods
Between April 1st and October 1st 2018, 138 consecutive AF inpatients were prospectively enrolled at the start or at the change or at the interruption of the OAC.
Results
The main characteristics of the cohort were: mean age 84,6 years (range 65–102), M/F = 64/74, mean Charlson score 4,4, mean ADL/IADL 3,45/2,01 and mean CHA2DS2VASc/ HAS-BLED scores 5/3. Thirty-eight percent (N=52) of patients needed walking aids. Polypharmacy (intake of ≥5 drugs) was present in 31,9% (N=44) of patients and anemia in 50% (N=69: acute 6,5%, chronic 34,8%, mixed 8,7%).
Half of the patients (N=69) presented new onset AF.
Only 68% of patients (N=47) with known AF (N=69) were in OAC (37,6% in VKAs and 30,4% in NOACs).
At the admission, the mean INR of AF in VKAs was 3,53 (range 1,54–10).
The hospital decision on the anticoagulation in 91 patients (22 with known AF not in OAC at home, and 69 with new-onset AF), defined as “naïve” to OAC, was evaluated: 26,3% (N=24) started NOACs, 45% (N=41)VKAs, 8,7% (N=8) anticoagulant low molecular weight heparin (EBPM), and 20% (N=18) didn't start OAC. The decision was supported by consultant cardiologists and/or angiologists in 72,5% of cases (N=66).
The choice of the VKAs was mainly due to chronic kidney disease (CKD) and acute kidney failure. Patients who started NOACs were significantly younger than those who started VKAs (age: 78,2 vs 86,5; p<0.001) and had a better preserved renal function (Cockroft-Gault GFR: 69,6 vs 48,1 ml/min; p<0.001). However, the mean GFR of VKAs patients was clearly above the lower limit set by the guidelines.
The main causes of the switching between NOACs and VKAs (N=14, 10,1%) were stroke-TIA occurrence (N=7, 57,1%) and CKD (N=4, 28,5%).
OAC was definitively interrupted (N=31, 22,4%) mostly for severe clinical conditions (N=16, 51,6%) and anemia (N=7, 22,5%).
Conclusions
In this “real life” cohort the deviation from the ESC guidelines was 52%. According to the guidelines only 11 (26,8%) of the patients who started VKAs would have been excluded from treatment with NOACs. Our experience underlines the presence of “fear” in the use of NOACs in geriatric patients, in particular with CKD.
Probably it's worth to question if the current guidelines provide reliable indications regarding the safety and manageability of the NOACs in the presence of the most common geriatric syndromes.
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A Simple Screening Tool to Predict Outcomes in Older Adults Undergoing Emergency General Surgery. J Am Geriatr Soc 2018; 67:309-316. [PMID: 30298686 DOI: 10.1111/jgs.15627] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 08/28/2018] [Accepted: 08/30/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To determine whether the Flemish version of the Triage Risk Screening Tool (fTRST) can be used to accurately assess frailty in an emergency setting. DESIGN Prospective observational study. SETTING of a tertiary referral hospital. PATIENTS All individuals aged 70 and older consecutively admitted to the emergency surgery unit with an urgent need for abdominal surgery between December 2015 and May 2016 who met inclusion criteria (N=110). MEASUREMENTS Individuals were screened with the fTRST and additional metrics such as the age-adjusted Charlson Comorbidity Index and American Society of Anesthesiology score. Thirty- and 90-day postoperative complications where recorded. Regression analyses were performed to identify possible preoperative predictors of adverse outcomes. RESULTS Thirty-day major complications (Clavien-Dindo Classification 3-5) occurred in 28.2% of participants (n=31). fTRST had the highest correlation with major complications (odds ratio (OR) = 7.42). All participants who died within 30 days of surgery has a fTRST score of 2 or greater (area under the receiver operating curve (AUC)=71.3). When risk factors for overall 90-day mortality were analyzed, a fTRST score of 2 or greater had sensitivity of 96% (95% confidence interval CI=79.6-99.9%), specificity of 43.5% (95% CI=32.8-54.7%) (AUC=69.8%; OR=18.50, 95% CI=2.39-143.11, p = .005). The average length of hospital stay was more than twice as long in the group with a fTRST score of 2 or greater (15.2 days) than in those with a score less than 2 (6.6 days) (p = .005). CONCLUSION The fTRST is an effective tool to predict mortality, morbidity, and length of stay after emergency surgery and can therefore be used to anticipate postoperative course, determine care goals, and plan for involvement of a dedicated geriatric care team. J Am Geriatr Soc 67:309-316, 2019.
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Effectiveness of a brief risk screening tool in detecting frailty in elderly patients undergoing emergency abdominal surgery. A pilot study. Eur J Surg Oncol 2018. [DOI: 10.1016/j.ejso.2018.01.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Intermediate care. ITALIAN JOURNAL OF MEDICINE 2013. [DOI: 10.4081/itjm.2010.57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: In most cases intermediate care is represented by a residential care service that faces needs of people, mainly older people, between discharge from the hospital and the return to home. Discussion: Some authors have a negative opinion of this system due to the risk of omission of care and malpractice for the elderly as a consequence of early discharge from the hospital. There are different models of implementation based on the resources locally available and on the particular facilities network. Conclusion: The multidimensional assessment of clinical, functional and social problems is the key for a favourable outcome of intermediate care. If appropriately built as organisational care, intermediate care can become a positive chance for patients’ health. The key for success is to operate in a patient-centered mode, by accurately defining the individual plan of care.
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A review on enteral tube feeding in demented patients: Ethical and organizational issues. Arch Gerontol Geriatr 1998. [DOI: 10.1016/s0167-4943(98)80069-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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