Abstract WP467: Challenging the National and Regional Targets and Achieving Door-to-Needle in 25 Minutes or Less at a Comprehensive Stroke Center

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Cynthia Sinogui ◽  
Hillary Mitchell ◽  
Anna Moiseyenko ◽  
Leslie Keear ◽  
Maraget Smith ◽  
...  
Keyword(s):  
Rapid Assessment ◽  
Baseline Data ◽  
Process Data ◽  
Treatment Target ◽  
Treatment Targets ◽  
Assessment And Treatment ◽  
Visual Aid ◽  
Local Facility ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: The American Heart/ American Stroke Association (AHA/ASA) established national 60 and 45-minute alteplase treatment targets ensure timely administration of alteplase in patients with acute ischemic stroke (AIS). To challenge the 21 facilities of our integrated health system, our organization established a treatment target of 30-minutes or less. To raise the bar further, our local facility set a treatment target of 25-minutes or less. Purpose: To streamline and standardize rapid assessment and treatment for AIS patients receiving alteplase in 25-minutes or less at a CSC. Methods: Baseline data and process timeline were reviewed, and the workflow was evaluated using real-time observations conducted by front-line staff. Staff, physicians, and former patients involved in cases that met the 30-minute target were interviewed. Several Plan-Do-Study-Act cycles were performed. An interdisciplinary subcommittee meets weekly to review cases for compliance and evaluation for process sustainability. An in-depth review is conducted for all cases outside the 25-minute treatment target. AHA/ASA exclusion criteria are allowed. Results: Baseline data was reviewed yielding 18% compliance to the target of 25-minute or less (3/16). Changes were implemented in April 2018. Between April 2018 and July 2019 of the 107 cases treated, 55% of cases were within 25-minutes, 81% within 30-minutes, 85% with 45-minutes, and 95% in 60-minutes. Keys to decreasing times were use of timer, a designated timekeeper, announcement of time increments, and revisions of the process. Data and other graphics were posted in the Stroke Alert vestibule as a visual aid for staff. Collaboration between departments was integral in driving change. Conclusion: Challenging national and organizational treatment targets and revising workflows were effective ways to sustain alteplase treatments times of 25-minutes or less.

Abstract TP360: Triage Nursing Intervention Improves Stroke Treatment Rate and Times for Walk-In Strokes

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Nayive Quezada ◽  
Ron Burke ◽  
Yaima Miro Gonzalez ◽  
Maygret Ramirez ◽  
Ivis C Gonzalez ◽  
...  
Keyword(s):  
Rapid Assessment ◽  
Community Outreach ◽  
Nursing Intervention ◽  
Treatment Rate ◽  
Stroke Treatment ◽  
Response Team ◽  
Emergency Department Triage ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
One Year

Introduction: Our comprehensive stroke center provides community outreach and stroke education to patients, caregivers, and community members on the importance of calling 911 in the event of a stroke. However, approximately 1/3 of our center’s stroke alerts are walk-ins. With a walk-in stroke, rapid assessment is essential because the stroke response team has no information compared to information that otherwise would be provided by EMS. As such, our center developed a rapid assessment by the emergency triage nurse or technician, who can then activate a stroke alert. Methods: The change to rapid stroke assessment and stroke alert activation by triage nurses and technicians (rather than waiting for an emergency physician to assess and activate a stroke alert) was made in March 2018. Cases from one year prior to the intervention were compared to cases from the year after implementation. Differences in turnaround times (door to stroke alert activation, door to needle [DTN]) were calculated. Results: In the period before implementation, there were 1200 stroke alerts, of which 420 arrived via triage (35%). Median door to stroke alert was 0 min. Of those who arrived through triage, 8 received IV alteplase (8/420=2%). For those patients, median DTN was 39 min. In contrast, after implementation, there were 1401 stroke alerts, of which 342 arrived via triage (24%). Median door to stroke alert was 2 min. Of those, 15 received IV alteplase (15/342=4%), with a median DTN of 32 min. Discussion: A nursing driven initiative at Emergency Department triage was effective at improving stroke treatment rate and decreasing DTN for IV alteplase for walk-in stroke patients.

scholarly journals Value of repeated imaging in patients with a stroke who are transferred for endovascular treatment

2021 ◽  
pp. neurintsurg-2020-017050
Author(s):  
Laura C C van Meenen ◽  
Nerea Arrarte Terreros ◽  
Adrien E Groot ◽  
Manon Kappelhof ◽  
Ludo F M Beenen ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Clinical Improvement ◽  
Treatment Delay ◽  
Clinical Deterioration ◽  
Large Vessel Occlusion ◽  
Intracranial Hemorrhages ◽  
Vessel Occlusion ◽  
Quality Outcomes ◽  
Comprehensive Stroke Center ◽  
Stroke Center

BackgroundPatients with a stroke who are transferred to a comprehensive stroke center for endovascular treatment (EVT) often undergo repeated neuroimaging prior to EVT.ObjectiveTo evaluate the yield of repeating imaging and its effect on treatment times.MethodsWe included adult patients with a large vessel occlusion (LVO) stroke who were referred to our hospital for EVT by primary stroke centers (2016–2019). We excluded patients who underwent repeated imaging because primary imaging was unavailable, incomplete, or of insufficient quality. Outcomes included treatment times and repeated imaging findings.ResultsOf 677 transferred LVO stroke, 551 were included. Imaging was repeated in 165/551 patients (30%), mostly because of clinical improvement (86/165 (52%)) or deterioration (40/165 (24%)). Patients who underwent repeated imaging had higher door-to-groin-times than patients without repeated imaging (median 43 vs 27 min, adjusted time difference: 20 min, 95% CI 15 to 25). Among patients who underwent repeated imaging because of clinical improvement, the LVO had resolved in 50/86 (58%). In patients with clinical deterioration, repeated imaging led to refrainment from EVT in 3/40 (8%). No symptomatic intracranial hemorrhages (sICH) were identified. Ultimately, 75/165 (45%) of patients with repeated imaging underwent EVT compared with 326/386 (84%) of patients without repeated imaging (p<0.01).ConclusionsNeuroimaging was repeated in 30% of patients with an LVO stroke and resulted in a median treatment delay of 20 minutes. In patients with clinical deterioration, no sICH were detected and repeated imaging rarely changed the indication for EVT. However, in more than half of patients with clinical improvement, the LVO had resolved, resulting in refrainment from EVT.

Effect of “drip-and-ship” and “drip-and-drive” on endovascular treatment of acute ischemic stroke with large vessel occlusion: a single-center retrospective study

2021 ◽  
pp. 028418512110068
Author(s):  
Yu Hang ◽  
Zhen Yu Jia ◽  
Lin Bo Zhao ◽  
Yue Zhou Cao ◽  
Huang Huang ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Primary Stroke Center ◽  
Secondary Endpoints ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background Patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) were usually transferred from a primary stroke center (PSC) to a comprehensive stroke center (CSC) for endovascular treatment (drip-and-ship [DS]), while driving the doctor from a CSC to a PSC to perform a procedure is an alternative strategy (drip-and-drive [DD]). Purpose To compare the efficacy and prognosis of the two strategies. Material and Methods From February 2017 to June 2019, 62 patients with LVO received endovascular treatment via the DS and DD models and were retrospectively analyzed from the stroke alliance based on our CSC. Primary endpoint was door-to-reperfusion (DTR) time. Secondary endpoints included puncture-to-recanalization (PTR) time, modified Thrombolysis in Cerebral Infarction (mTICI) rates at the end of the procedure, and modified Rankin Scale (mRS) at 90 days. Results Forty-one patients received the DS strategy and 21 patients received the DD strategy. The DTR time was significantly longer in the DS group compared to the DD group (315.5 ± 83.8 min vs. 248.6 ± 80.0 min; P < 0.05), and PTR time was shorter (77.2 ± 35.9 min vs. 113.7 ± 69.7 min; P = 0.033) compared with the DD group. Successful recanalization (mTICI 2b/3) was achieved in 89% (36/41) of patients in the DS group and 86% (18/21) in the DD group ( P = 1.000). Favorable functional outcomes (mRS 0–2) were observed in 49% (20/41) of patients in the DS group and 71% (15/21) in the DD group at 90 days ( P = 0.089). Conclusion Compared with the DS strategy, the DD strategy showed more effective and a trend of better clinical outcomes for AIS patients with LVO.

scholarly journals Coronavirus disease 2019 is threatening stroke care systems: a real-world study

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Jiawei Xin ◽  
Xuanyu Huang ◽  
Changyun Liu ◽  
Yun Huang
Keyword(s):  
Real World ◽  
Mainland China ◽  
Stroke Care ◽  
Hospital Length ◽  
Real World Data ◽  
Care Systems ◽  
Long Term Prognosis ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Medical Burden

Abstract Background Since the onset of the coronavirus disease 2019 (COVID-19) pandemic, the stroke care systems have been seriously affected because of social restrictions and other reasons. As the pandemic continues to spread globally, it is of great significance to understand how COVID-19 affects the stroke care systems in mainland China. Methods We retrospectively studied the real-world data of one comprehensive stroke center in mainland China from January to February 2020 and compared it with the data collected during the same period in 2019. We analyzed DTN time, onset-to-door time, severity, effects after treatment, the hospital length of stays, costs of hospitalization, etc., and the correlation between medical burden and prognosis of acute ischemic stroke (AIS) patients. Results The COVID-19 pandemic was most severe in mainland China in January and February 2020. During the pandemic, there were no differences in pre-hospital or in-hospital workflow metrics (all p>0.05), while the degree of neurological deficit on admission and at discharge, the effects after treatment, and the long-term prognosis were all worse (all p<0.05). The severity and prognosis of AIS patients were positively correlated with the hospital length of stays and total costs of hospitalization (all p<0.05). Conclusions COVID-19 pandemic is threatening the stroke care systems. Measures must be taken to minimize the collateral damage caused by COVID-19.

How do treatment times impact on functional outcome in stroke patients undergoing thrombectomy in Germany? Results from the German Stroke Registry

2021 ◽  
pp. 174749302098526
Author(s):  
Juliane Herm ◽  
Ludwig Schlemm ◽  
Eberhard Siebert ◽  
Georg Bohner ◽  
Anna C Alegiani ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Odds Ratio ◽  
Intravenous Thrombolysis ◽  
Stroke Patients ◽  
Poor Functional Outcome ◽  
Stroke Registry ◽  
Primary Stroke Center ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Center Time

Background Functional outcome post-stroke depends on time to recanalization. Effect of in-hospital delay may differ in patients directly admitted to a comprehensive stroke center and patients transferred via a primary stroke center. We analyzed the current door-to-groin time in Germany and explored its effect on functional outcome in a real-world setting. Methods Data were collected in 25 stroke centers in the German Stroke Registry-Endovascular Treatment a prospective, multicenter, observational registry study including stroke patients with large vessel occlusion. Functional outcome was assessed at three months by modified Rankin Scale. Association of door-to-groin time with outcome was calculated using binary logistic regression models. Results Out of 4340 patients, 56% were treated primarily in a comprehensive stroke center and 44% in a primary stroke center and then transferred to a comprehensive stroke center (“drip-and-ship” concept). Median onset-to-arrival at comprehensive stroke center time and door-to-groin time were 103 and 79 min in comprehensive stroke center patients and 225 and 44 min in primary stroke center patients. The odds ratio for poor functional outcome per hour of onset-to-arrival-at comprehensive stroke center time was 1.03 (95%CI 1.01–1.05) in comprehensive stroke center patients and 1.06 (95%CI 1.03–1.09) in primary stroke center patients. The odds ratio for poor functional outcome per hour of door-to-groin time was 1.30 (95%CI 1.16–1.46) in comprehensive stroke center patients and 1.04 (95%CI 0.89–1.21) in primary stroke center patients. Longer door-to-groin time in comprehensive stroke center patients was associated with admission on weekends (odds ratio 1.61; 95%CI 1.37–1.97) and during night time (odds ratio 1.52; 95%CI 1.27–1.82) and use of intravenous thrombolysis (odds ratio 1.28; 95%CI 1.08–1.50). Conclusion Door-to-groin time was especially relevant for outcome of comprehensive stroke center patients, whereas door-to-groin time was much shorter in primary stroke center patients. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT03356392 . Unique identifier NCT03356392

Abstract WMP88: Shorter Door-to-Needle Times of Intravenous Alteplase Improve “Efficiency” of Care and Moderately Affect “Quality” of Care: Study Based on a Large Comprehensive Stroke Center

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Suja S Rajan ◽  
Jessica N Wise ◽  
Marquita Decker-palmer ◽  
Thanh Dao ◽  
Cynthia Salem ◽  
...  
Keyword(s):  
Quality Of Care ◽  
Clinical Outcomes ◽  
Heart Association ◽  
P Value ◽  
Regression Analyses ◽  
Inpatient Mortality ◽  
Care Outcomes ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Introduction: The American Heart Association (AHA) recently raised the bar on timely treatment of acute ischemic stroke (AIS) with intravenous (IV) alteplase, by recommending door-to-needle times of 30 minutes or less for 50% or more of the AIS patients. Our study looks at the effectiveness of this new standard, by examining the effect of varying door-to-needle times on efficiency and quality of care, and clinical outcomes. Methods: Our study examined 762 AIS patients treated with IV alteplase in a large academic health system from 2015-2018, and compared their outcomes after treatment within 30, 45 and 60 minutes of arrival. The outcomes compared were: 1) Efficiency of care outcome - Length of stay (LOS); 2) Quality of care outcomes - Inpatient mortality and Disability at discharge; 3) Clinical outcomes - Discharge and 90-day modified Rankin Scale (mRS), and Post-alteplase (24 hr) NIH Stroke Scale (NIHSS). Adjusted logistic and linear regression analyses were used, after controlling for baseline patient socio-demographic and clinical characteristics. Results: Based on the adjusted regression analyses (Table 1), being treated within 30 minutes of arrival reduced the average LOS by 1.3 days (p-value: 0.02), but did not affect the quality of care outcomes. Similarly, being treated within 45 minutes of arrival reduced LOS by 0.9 days (p-value: 0.04). Being treated within 60 minutes of arrival did not affect LOS, but reduced the odds of inpatient mortality by 68% (p-value: 0.00), and disability at discharge by 29% (p-value: 0.08). Being treated within 30 minutes of arrival was associated with better mRS and NIHSS scores as compared with being treated within 45 or 60 minutes. Conclusion: Quicker IV alteplase treatment significantly improved efficiency of care and clinical outcomes. Quality of care outcomes did not improve beyond the 60 minute door-to-needle threshold. This study provides evidence supporting AHA’s new recommendation of 30 minutes or less door-to-needle time.

Abstract WP322: Inability to Identify Physician is Associated With Medication and Care Plan Knowledge Gaps Ii Stroke Patients

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Fred Cohen ◽  
Jeffrey M Katz ◽  
Jackie McCarthy ◽  
Ignacio Lopez ◽  
Paul Wright
Keyword(s):  
Medication Compliance ◽  
Care Plan ◽  
Medication Regimen ◽  
Stroke Patients ◽  
General Neurology ◽  
Patient Dissatisfaction ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Knowledge Deficits ◽  
Attending Physician

Introduction: Patient dissatisfaction and medication non-compliance correlate with patient misunderstanding of their medications and care plan. We aimed to assess the degree of these gaps and their associations in hospitalized stroke patients. Methods: A 5-question survey was administered to patients hospitalized on the neuroscience ward of a comprehensive stroke center. Patient understanding of their condition leading to admission, care plan, medications, primary attending physician, and follow-up plan was assessed. If the patient was unable to communicate, then their health care representative was interviewed. Results: A total of 146 patients (55 stroke and 91 general neurology and neurosurgery (non-stroke) patients) or their representatives were interviewed. Stroke patients were less likely to properly identify their primary attending physician (33/55 (60.0%) stroke patients versus 35/91 (38.5%) non-stroke patients; p=0.011). Inability to identify the attending physician was associated with lack of medication and care plan knowledge and was more common in stroke patients, (23/33 (69.7%) stroke patients versus 14/35 (40.0%) non-stroke patients; p=0.014). Conclusion: Despite sharing a common pool of providers, the inability to identify the primary attending physician was significantly more common in stroke patients and was associated with patient knowledge deficits regarding their medication regimen and care plan. This correlation was significantly higher in stroke patients and suggests that stroke patients may require different, extra or more robust communication and education than the general neurology and neurosurgery population. Additionally, emphasis on attending physician identification may improve patient satisfaction and medication compliance.

Impact of RapidAI mobile application on treatment times in patients with large vessel occlusion

2021 ◽  
pp. neurintsurg-2021-017365
Author(s):  
Mais Al-Kawaz ◽  
Christopher Primiani ◽  
Victor Urrutia ◽  
Ferdinand Hui
Keyword(s):  
Mobile Application ◽  
Secondary Analysis ◽  
Multiple Linear Regression Model ◽  
Stroke Care ◽  
Mobile App ◽  
Large Vessel ◽  
Vessel Occlusion ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Adjusted Model

BackgroundCurrent efforts to reduce door to groin puncture time (DGPT) aim to optimize clinical outcomes in stroke patients with large vessel occlusions (LVOs). The RapidAI mobile application (Rapid Mobile App) provides quick access to perfusion and vessel imaging in patients with LVOs. We hypothesize that utilization of RapidAI mobile application can significantly reduce treatment times in stroke care by accelerating the process of mobilizing stroke clinicians and interventionalists.MethodsWe analyzed patients presenting with LVOs between June 2019 and October 2020. Thirty-one patients were treated between June 2019 and March 2020 (pre-app group). Thirty-three patients presented between March 2020 and October 2020 (post-app group). Mann–Whitney U test and Kruskal–Wallis tests were used to examine variables that are not normally distributed. In a secondary analysis we analyzed interhospital time metrics between primary stroke centers and our comprehensive stroke center.ResultsBaseline demographic and vascular risk factors were similar in both groups. Use of Rapid Mobile App resulted in 33 min reduction in DGPT (P=0.02), 35 min reduction in door to first pass time (P=0.02), and 37 min reduction in door to recanalization time (P=0.02) in univariate analyses when compared with patients treated pre-app. In a multiple linear regression model, utilization of Rapid Mobile App significantly predicted shorter DGPT (P=0.002). In an adjusted model, National Institutes of Health Stroke Scale (NIHSS) 24 hours after procedure and at discharge were significantly lower in the post-app group (P=0.03). Time of transfer between primary and comprehensive stroke center was comparable in both groups (P=0.26).ConclusionIn patients with LVOs, the implementation of the RapidAI mobile application was independently associated with reductions in intrahospital treatment times.

Abstract 3313: Outcomes of “Drip-and-Ship” Paradigm Among Patients with Acute Ischemic Stroke. Results of a State Wide Study

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Saqib A Chaudhry ◽  
Gustavo J Rodriguez ◽  
M. Fareed K Suri ◽  
Adnan I Qureshi
Keyword(s):  
Ischemic Stroke ◽  
Recombinant Tissue Plasminogen Activator ◽  
Population Based ◽  
Primary Diagnosis ◽  
Hospital Charges ◽  
Stroke Patients ◽  
Frequency Distributions ◽  
Number Of Patients ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: “Drip-and-ship” denotes patients in whom intravenous (IV) recombinant tissue plasminogen activator (rt-PA) is initiated at the emergency department (ED) of a community hospital, followed by transfer within 24 hours to a comprehensive stroke center. Although drip-and-ship paradigm has the potential to increase the number of patients who receive IV rt-PA, comparative outcomes have not been assessed at a population based level. Methods: State-wide estimates of thrombolysis, associated in-hospital outcomes and mortality were obtained from 2008-2009 Minnesota Hospital Association (MHA) data. Patient numbers and frequency distributions were calculated for state-wide sample of patients hospitalized with a primary diagnosis of ischemic stroke. Patients outcomes were analyzed after stratification into patients treated with IV rt-PA through primary ED arrival or drip-and-ship paradigm. Results: Of the 21,024 admissions, 602 (2.86%) received IV rt-PA either through primary ED arrival (n=473) or drip-and-ship paradigm (n=129). The rates of secondary intracerebral or subarachnoid hemorrhage were higher in patients treated with IV rt-PA through primary ED arrival compared with those treated with drip-and-ship paradigm (8.5% versus 3.1, p=0.038). The in-hospital mortality rate was similar among ischemic stroke patients receiving IV rt-PA through primary ED arrival or drip-and-ship paradigm (5.9% versus 7.0%). The mean hospital charges were $65,669 for primary ED arrival and $47,850 for drip-and-ship treated patients (p<0.001). Conclusions: The results of drip-and-ship paradigm compare favorably with IV rt-PA treatment through primary ED arrival in this state-wide study.

Abstract 83: Etiology of Late Right-to-Left Shunting on Transcranial Doppler in Ischemic Stroke Patients

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Adam de Havenon ◽  
Anne Moore ◽  
Nicholas Freeberg ◽  
Ali Sultan-Qurraie ◽  
David Tirschwell
Keyword(s):  
Ischemic Stroke ◽  
Transcranial Doppler ◽  
Inclusion Criteria ◽  
Contrast Injection ◽  
Stroke Patients ◽  
Stroke Etiology ◽  
Standard Component ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Toast Classification

Background: An echocardiogram or transcranial Doppler (TCD) bubble study to test for a right-to-left shunt (RLS) is a standard component of an ischemic stroke workup. Because the pathway for an intracradiac RLS, such as a patent foramen ovale (PFO), is more direct, it has been proposed that the late appearance of a RLS suggests an extracardiac pathway. We sought to characterize a cohort of ischemic stroke patients with late RLS (LRLS) on TCD. Methods: We searched the medical record of a Comprehensive Stroke Center for patients with ischemic stroke who had a TCD and echocardiogram bubble study during 2011-2013. LRLS was defined as TCD bubbles appearing more than 18 cardiac cycles after contrast injection. TOAST stroke etiology classification was performed by a vascular neurologist blinded to TCD results. Results: 124 patients met inclusion criteria, of which 67/124 (54%) had RLS on TCD; and 32/67 (48%) had LRLS. In the 35/67 patients with normal RLS on TCD, 23% did not have RLS on echocardiography, consistent with prior reports of TCD’s superiority for detecting RLS. In the 32/67 patients with LRLS on TCD, 56% were negative for RLS by echocardiography. In the cohort of 124 patients, the percentage of TOAST classification 4 (stroke of other determined cause) was 26%, while in the 32 patients with LRLS the percentage of TOAST 4 was significantly higher at 52%(p=0.005) (Table 1). The increase in TOAST 4 in LRLS patients was created by an even distribution of decreases in the other TOAST categories. The most common TOAST 4 stroke etiology in LRLS patients was PFO with concurrent deep venous thrombosis. Conclusion: This preliminary data supports prior studies that have shown superiority of TCD over echocardiography for detection of RLS, and challenge the prevailing notion that extracardiac shunt, such as pulmonary AVM, is the most common cause of LRLS in ischemic stroke patients. This subgroup of patients warrants further research to clarify mechanisms of ischemic stroke in patients with RLS.

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