scholarly journals Updated Evidence on the Epidemiology of Hepatitis C Virus in Hemodialysis

Pathogens ◽  
2021 ◽  
Vol 10 (9) ◽  
pp. 1149
Author(s):  
Fabrizio Fabrizi ◽  
Roberta Cerutti ◽  
Piergiorgio Messa
Keyword(s):  
Infection Control ◽  
De Novo ◽  
Antiviral Treatment ◽  
Developed Countries ◽  
Hemodialysis Patients ◽  
Nosocomial Transmission ◽  
Hemodialysis Unit ◽  
Dialysis Vintage ◽  
Dialysis Outcomes ◽  
The Impact

Prevalence rates of HCV infection are decreasing in hemodialysis units of most developed countries; however, nosocomial transmission of HCV continues to occur in the hemodialysis setting, not only in the emerging world. According to the Dialysis Outcomes and Practice Patterns Study (DOPPS, 2012–2015), the prevalence of HCV among patients on regular hemodialysis was 9.9%; in incident patients, the frequency of HCV was approximately 5%. Outbreaks of HCV have been investigated by epidemiologic and phylogenetic data obtained by sequencing of the HCV genome; no single factor was retrieved as being associated with nosocomial transmission of HCV within hemodialysis units. Transmission of HCV within HD units can be prevented successfully by full compliance with infection control practices; also, antiviral treatment and serologic screening for anti-HCV can be useful in achieving this aim. Infection control practices in hemodialysis units include barrier precautions to prevent exposure to blood-borne pathogens and other procedures specific to the hemodialysis environment. Isolating HCV-infected hemodialysis patients or using dedicated dialysis machines for HCV-infected patients are not currently recommended; reuse of dialyzers of HCV-infected patients should be made, according to recent guidelines. Randomized controlled trials regarding the impact of isolation on the risk of transmission of HCV to hemodialysis patients have not been published to date. At least two studies showed complete elimination of de novo HCV within HD units by implementation of strict infection control practices without isolation practices. De novo HCV within hemodialysis units has been independently associated with facility HCV prevalence, dialysis vintage, and low staff-to-patient ratio. Antiviral treatment of HCV-infected patients on hemodialysis should not replace the implementation of barrier precautions and other routine hemodialysis unit procedures.

scholarly journals Application of Multicriteria Decision Making and Multi-Objective Planning Methods for Evaluating Metropolitan Parks in Terms of Budget and Benefits

Mathematics ◽  
2020 ◽  
Vol 8 (8) ◽  
pp. 1304 ◽  
Author(s):  
Wen-Chi Lo ◽  
Ching-Hua Lu ◽  
Ying-Chyi Chou
Keyword(s):  
Decision Making ◽  
Resource Utilization ◽  
De Novo ◽  
Social Indicators ◽  
Multicriteria Decision Making ◽  
Developed Countries ◽  
Multicriteria Decision ◽  
Multi Objective ◽  
Planning Methods ◽  
The Impact

Urbanization is inevitable in developed countries. This study investigated the design of metropolitan parks, which are essential for sustainable cities. The developed model examined the suitability of parks in Taichung City, Taiwan, and explored the three aspects of ecological, economic, and social indicators for park design using De Novo planning tools and the Decision Making Trial and Evaluation Laboratory-based Analytic Network Process. Because the De Novo programming method can redesign budget restrictions, this method can help managers arrange budget programming and reduce the impact of excessive investment on resource utilization in specific projects. After obtaining each factor’s price, the De Novo planning approach can reduce economic and ecological resource input and improve benefits relative to existing resource utilization methods. When assuming a fixed investment of resources, the De Novo planning method moves resources from the economic and ecological aspects of leisure and recreation, thus increasing the total benefit of metropolitan parks. Multicriteria decision-making and multi-objective planning methods can provide an effective solution for evaluating metropolitan parks.

scholarly journals MO664DYNAMIC ASSESSMENT OF INTERLEUKIN-6 DURING HEMODIALYSIS AND MORTALITY IN COVID 19

2021 ◽  
Vol 36 (Supplement_1) ◽  
Author(s):  
Patricia Muñoz Ramos ◽  
Martin Giorgi ◽  
Yohana Gil Giraldo ◽  
Antonio De Santos ◽  
Almudena Núñez ◽  
...  
Keyword(s):  
Interleukin 6 ◽  
Hemodialysis Patients ◽  
Dialysis Session ◽  
Serum Samples ◽  
X Ray ◽  
Factors Associated ◽  
Positive Balance ◽  
Dialysis Vintage ◽  
Chest X Ray ◽  
The Impact

Abstract Background and Aims The impact of the newly discovered severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing coronavirus disease-19 (COVID-19) in hemodialysis patients remains poorly characterized. Some hemodialysis techniques reduce systemic inflammation but their impact on COVID-19 has not been addressed. The aim of this prospective study was to evaluate factors associated to mortality in COVID-19 hemodialysis patients, including the impact of reducing interleukin-6 using a cytokine adsorbent filter. Method This is a prospective single-center study including 16 hemodialysis patients with COVID-19. All were dialyzed using a polymethyl methacrylate (PMMA) filter. Interleukin-6 levels were obtained before and after the first admission hemodialysis session and at one week. Also we collected serum samples from 8 patients of our unit as controls: 4 in online hemodiafiltration (OLHDF) and 4 in high-flux hemodialysis Baseline comorbidities, laboratory values, chest X-ray and treatments were recorded and compared between survivors and non-survivors. Results Sixteen patients were included (13 males, mean age 72±15 years). Four patients (25%) died. Factors associated to mortality were dialysis vintage (p=0.01), the presence of infiltrates in chest X-ray (p=0.032), serum C-reactive protein (p=0.05) and lactate dehydrogenase (p=0.02) at one week, the requirement of oxygen therapy (p=0.02) and the use of anticoagulation (p<0.01). At admission, post-dialysis interleukin-6 levels were higher (p<0.01) in non-survivors and these patients differed from survivors in the reduction of interleukin-6 levels during the dialysis session despite using a PMMA filter (survivors vs non survivors (25 [17-53]% vs -3 [-109-12] %, p=0.04). Conclusion In hemodialysis COVID-19 patients, a positive balance of interleukin-6 during the session was associated to higher mortality.

Chronic Hemodialysis Patients. Part II: Reducing Drug-Related Problems through Application of the Focused Drug Therapy Review Program

1994 ◽  
Vol 28 (3) ◽  
pp. 320-324 ◽  
Author(s):  
Barbara Kaplan ◽  
Leslie A. Shimp ◽  
Nancy A. Mason ◽  
Frank J. Ascione
Keyword(s):  
Drug Therapy ◽  
Pharmacy Practice ◽  
Hemodialysis Patients ◽  
Chronic Hemodialysis ◽  
University Hospital ◽  
Endstage Renal Disease ◽  
Implementation Evaluation ◽  
Hemodialysis Unit ◽  
Therapeutic Recommendations ◽  
The Impact

OBJECTIVE: To test the value and measure the impact of a model of pharmacy practice called the Focused Drug Therapy Review Program (FDTRP)in patients with endstage renal disease on hemodialysis. DESIGN: A modified version of FDTRP, adapted for a hemodialysis population, was assessed for its impact on prescriber behavior. The impact was measured by examining the percentage of pharmacist therapeutic recommendations accepted and implemented by the prescriber. SETTING: Thirty patients at a university hospital-based outpatient hemodialysis unit participated in the study. Twenty-four patients completed the study through the implementation evaluation. RESULTS: The pharmacist generated 114 therapeutic recommendations and 85 informative comments regarding drug therapy. The prescriber accepted 76 percent and implemented 70 percent of the therapeutic recommendations. The prescriber considered the informative comments to be helpful, even if the information was known previously. CONCLUSIONS: The FDTRP has been shown to be useful in the care of chronic hemodialysis patients. In addition, the pharmacist was able to provide clinically important recommendations in a closely monitored patient population.

scholarly journals Changes in Quality of Life in Older Hemodialysis Patients: A Cohort Study on Dialysis Outcomes and Practice Patterns

2020 ◽  
Vol 51 (8) ◽  
pp. 650-658
Author(s):  
Ayumi Ishiwatari ◽  
Shungo Yamamoto ◽  
Shingo Fukuma ◽  
Takeshi Hasegawa ◽  
Sachiko Wakai ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Practice Patterns ◽  
Hemodialysis Patients ◽  
Maintenance Hemodialysis ◽  
Dialysis Vintage ◽  
Health Related Qol ◽  
Health Related ◽  
Dialysis Outcomes ◽  
Maintenance Hemodialysis Patients

Background: Despite improvements in dialysis treatment, mortality rates remain high, especially among older hemodialysis patients. Quality of life (QOL) among hemodialysis patients is strongly associated with higher risk of death. This study aimed to describe the health-related QOL and its change in older maintenance hemodialysis patients and to demonstrate characteristics associated with health-related QOL. Methods: Data on 892 maintenance hemodialysis patients aged 60 years or older who were surveyed using the Kidney Disease Quality of Life Short Form at baseline and 2 years after study enrollment in phases 4 (2009–2011) and 5 (2012–2014) of the Japanese Dialysis Outcomes and Practice Patterns Study were analyzed. We categorized participants into 3 age groups (60–69, 70–79, and ≥80 years) and described baseline physical component summary (PCS) and mental component summary (MCS) scores, as well as their distribution of changes after 2 years across each category. Results: Hemodialysis patients aged 70–79 years and ≥80 years had lower PCS scores than those aged 60–69 years (median: 70–79 years = 43.1; interquartile range [IQR], 35.2–49.4; ≥80 years = 38.8; IQR, 31.6–43.8; 60–69 years = 45.4; IQR, 37.5–51.4; p < 0.001). In contrast, MCS scores did not significantly differ by age category (70–79 years = 45.6; IQR, 38.4–53.7; ≥80 years = 45.4; IQR, 36.9–55.1; 60–69 years = 46.8; IQR, 39.5–55.7; p = 0.1). As dialysis vintage lengthened, the PCS score significantly became lower, whereas no association was found with change in the MCS score. The MCS score declined over time in older patients, especially among those aged 80 years and older after 2 years’ follow-up. Conclusions: Physical QOL became worse as dialysis vintage lengthened. In contrast, mental QOL declined over time within a relatively short period among older maintenance hemodialysis patients.

scholarly journals P1440ASSOCIATION BETWEEN THE USE OF DRUGS FOR CONSTIPATION AND MORTALITY IN HEMODIALYSIS PATIENTS; FROM JAPAN-DIALYSIS OUTCOMES AND PRACTICE PATTERNS STUDY (J-DOPPS)

2020 ◽  
Vol 35 (Supplement_3) ◽  
Author(s):  
Seiji Itano ◽  
Yu Honda ◽  
Eiji Kubo ◽  
Yosuke Yamada ◽  
Tatsuyoshi Ikenoue ◽  
...  
Keyword(s):  
Risk Factors ◽  
Practice Patterns ◽  
Cardiovascular Death ◽  
Hemodialysis Patients ◽  
Gastrointestinal Complications ◽  
Cox Regression Analysis ◽  
Risk Of Death ◽  
Dialysis Vintage ◽  
Dialysis Outcomes ◽  
Observation Period

Abstract Background and Aims Hemodialysis patients have a high prevalence of constipation related to medication use, water restriction, insufficient dietary fiber intake, and reduced physical activity. Thus, these patients use drugs for constipation (DFC) more than five times that used by healthy individuals. In hemodialysis patients, two pathological factors, namely, reduced defecation function and DFC use itself, occur. These factors could be related to deteriorating life prognosis resulting from altered intestinal microbiota, gastrointestinal complications, or declining quality of life. In the general population, some reports have suggested that constipation and DFC use are risk factors of coronary artery disease, cardiovascular death, or all-cause death. However, whether such risk factors are appropriate for hemodialysis patients has not been clarified. This study aimed to investigate the association between DFC use and risk of death in hemodialysis patients. Method In this prospective cohort study based on the Japan-Dialysis Outcomes and Practice Patterns Study (J-DOPPS), we used J-DOPPS phase 1-5 (1998-2015) data. Hemodialysis patients enrolled in the J-DOPPS whose dialysis vintage was &gt;3 months (n=12,217) were divided into two groups according to usage (DFC group;n=3,721) and non-usage (non-DFC group;n=8,496) of DFC. The primary endpoint was all-cause death. Secondary endpoints were deaths from infection, malignancy, and cardiovascular causes. Hazard ratio (HR) was calculated using multilevel Cox regression analysis with facility level. Potential confounders were adjusted by the inverse probability of treatment weighting using the propensity score. Rubin’s rule was used for combined data. Sensitivity analysis was conducted using instrumental variable method to assess the effect of unmeasured confounders. Missing data were imputed using multilevel multiple imputation repeated 20 times. Results DFCs were prescribed in 30.5% of patients at baseline. Over a median follow-up of 730 [418, 974] days, 1,240 deaths from any cause were noted. Overall data were analyzed first. Although DFC use was associated with increased mortality risk (adjusted HR, 1.12; 95% confidence interval [CI] 1.03, 1.21), proportional assumptions were not met (Figure). Then, we only analyzed data of patients with observation period &gt;1.5 years. In this study, 8,345 patients had an observation period &gt;1.5 years, DFCs were prescribed in 31.0% of patients at baseline, and 389 patients died from any cause. Marked difference was observed after 1.5 years from baseline (adjusted HR, 1.35; 95% CI, 1.17, 1.55). Risks for deaths from infections (adjusted HR 1.62; 95% CI 1.14, 2.29) and malignancy (adjusted HR 1.60; 95% CI, 1.08, 2.36) were higher in the DFC group, but no difference in cardiovascular death risk was found (adjusted HR 1.11; 95% CI, 0.91, 1.36). Conclusion In hemodialysis patients, DFC use was associated with an increased risk of death. Thus, it may be important to manage defecation habit without using DFC by modulating intake of dietary fibers, exercise, or use of medications that are less likely to cause constipation.

scholarly journals P1532PARATHYROID HORMONE SERUM LEVELS AND MORTALITY AMONG HEMODIALYSIS PATIENTS IN THE GULF COOPERATION COUNCIL COUNTRIES: RESULTS FROM THE DOPPS (2012-2018)

2020 ◽  
Vol 35 (Supplement_3) ◽  
Author(s):  
Issa Al Salmi ◽  
Brian Bieber ◽  
Mona AlRukhaimi ◽  
Ali AlSahow ◽  
Faissal Shaheen ◽  
...  
Keyword(s):  
United Arab Emirates ◽  
Cox Regression ◽  
Serum Levels ◽  
Gulf Cooperation Council ◽  
Hemodialysis Patients ◽  
Phosphate Binders ◽  
Mortality Pattern ◽  
Cell Counts ◽  
Dialysis Vintage ◽  
Dialysis Outcomes

Abstract Background and Aims The prospective Dialysis Outcomes and Practice Patterns Study (DOPPS) has collected data since 2012 in all six Gulf cooperation council (GCC) countries (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, United Arab Emirates). Here, we report the relationship of PTH with mortality in this largest GCC hemodialysis patient cohort studied to date. Method Data were from randomly-selected national samples of hemodialysis facilities in GCC DOPPS phases 5 and 6 (2012-2018). PTH descriptive findings and case-mix adjusted PTH/mortality Cox regression analyses were based on 1825 and 1422 randomly-selected hemodialysis patients, respectively. Results Mean patient age was 55 years (median dialysis vintage = 2.1 years). Median PTH ranged from 259 pg/mL (UAE) to 437 pg/mL (Kuwait), with 22% having PTH &lt;150 pg/mL, 24% (PTH 150-300), 34% (PTH 301-700), and 20% (PTH &gt;700) pg/mL. Patients with PTH &gt;700 pg/mL were younger, on dialysis longer, less likely to be diabetic, have urine&gt;200 mL/day, prescribed 3.5 mEq/L dialysate calcium, had higher mean serum creatinine and phosphorus levels, lower white blood cell counts, and more likely to be prescribed cinacalcet, phosphate binders, or IV vitamin D. A “U-shaped” PTH/mortality relationship was observed with &gt;2-fold and 1.5 fold higher adjusted HR of death at PTH&gt;700 pg/mL and &lt;300 pg/mL, respectively, compared to PTH 301-450 pg/mL. Conclusion Secondary hyperparathyroidism is highly prevalent among GCC hemodialysis patients, with a strong U-shaped PTH/mortality relationship seen at PTH &lt;300 and &gt;450 pg/mL. Future studies are encouraged for further understanding this PTH/mortality pattern in relationship to unique aspects of the GCC hemodialysis population.

]Socioeconomic Factors May Select Adults Younger Than 60 Years of Age with “De Novo” Acute Myeloid Leukemia To Receive Intensive Treatment outside a Clinical Trial in Developing Countries. Experience of a Brazilian University Center.

Blood ◽  
2004 ◽  
Vol 104 (11) ◽  
pp. 4517-4517
Author(s):  
Evandro M. Fagundes ◽  
Vanderson Rocha ◽  
Ana Beatriz F. Glória ◽  
Nelma Cristina D. Clementino ◽  
José S. Quintão ◽  
...  
Keyword(s):  
Treatment Outcomes ◽  
De Novo ◽  
Developed Countries ◽  
Intensive Treatment ◽  
Remission Induction ◽  
Lower Probability ◽  
High Dose ◽  
University Center ◽  
The Impact ◽  
To Receive

Abstract Socioeconomic status (SES) is associated with treatment outcomes of ALL childhood. Whether this factor is associated with outcomes in adults AML in a developing country is not known. We have studied the impact of the human development index (HDI) of the United Nations as a SES factor for treatment outcomes of adults with “de novo” AML. Among 124 consecutive patients retrospectively analyzed, 46 (37 %) died during induction, 66 reached complete remission (53%) and 46 (37%) received high dose Ara-C (Hidac) consolidation. Five years-overall survival (OS) and leukemia free survival (LFS) were 17%±3% and 26%±6% respectively for all patients and 36%±7% and 30%±7% respectively for those receiving Hidac. In multivariate analysis, the HDI lower than 0.660 was associated with lower probability to receive Hidac (p=0.001), a trend for higher mortality in remission induction (p=0.062) and a decreased LFS (p&lt;0.0001), however it was not associated with outcomes for patients receiving Hidac. In conclusion, survival for patients who received Hidac consolidation is similar to those reported in developed countries, but results of overall outcomes are inferior, probably due to the influence of socio-economic factors before Hidac consolidation. Poor SES may be a factor associated with patient selection for intensive treatment and survival.

scholarly journals Hepatitis B Vaccination Response in Hemodialysis Patients: The Impact of Dialysis Shift

2021 ◽  
pp. 1-8
Author(s):  
Maggie Han ◽  
Xiaoling Ye ◽  
Sharon Rao ◽  
Schantel Williams ◽  
Stephan Thijssen ◽  
...  
Keyword(s):  
Hepatitis B ◽  
Multivariate Regression ◽  
Clinical Laboratory ◽  
Seroconversion Rate ◽  
Hemodialysis Patients ◽  
Hepatitis B Vaccination ◽  
Start Time ◽  
Vaccination Response ◽  
Dialysis Vintage ◽  
The Impact

<b><i>Background/Aims:</i></b> Hepatitis B (HB) vaccination in hemodialysis patients is important as they are at a higher risk of contracting HB. However, hemodialysis patients have a lower HB seroconversion rate than their healthy counterparts. As better sleep has been associated with better seroconversion in healthy populations and early hemodialysis start has been linked to significant sleep-wake disturbances in hemodialysis patients, we examined if hemodialysis treatment start time is associated with HB vaccination response. <b><i>Methods:</i></b> Demographics, standard-of-care clinical, laboratory, and treatment parameters, dialysis shift data, HB antigen status, HB vaccination status, and HB titers were collected from hemodialysis patients in Fresenius clinics from January 2010 to December 2015. Patients in our analysis received 90% of dialysis treatments either before or after 8:30 a.m., were negative for HB antigen, and received a complete series of HB vaccination (Engerix B® or Recombivax HB™). Univariate and multivariate regression models examined whether dialysis start time is a predictor of HB vaccination response. <b><i>Results:</i></b> Patients were 65 years old, 57% male, and had a HD vintage of 10 months. Patients whose dialysis treatments started before 8:30 a.m. were more likely to be younger, male, and have a greater dialysis vintage. Patients receiving Engerix B® and starting dialysis before 8:30 a.m. had a significantly higher seroconversion rate compared to patients who started dialysis after 8:30 a.m. Early dialysis start was a significant predictor of seroconversion in univariate and multivariate regression including male gender, but not in multivariate regression including age, neutrophil-to-lymphocyte ratio, and vintage. <b><i>Conclusion:</i></b> While better sleep following vaccination is associated with seroconversion in the general population, this is not the case in hemodialysis patients after multivariate adjustment. In the context of end-stage kidney disease, early dialysis start is not a significant predictor of HB vaccination response. The association between objectively measured postvaccination sleep duration and seroconversion rate should be investigated.

Contact precautions for colonisation with multidrug-resistant organisms and haemodialysis patient quality of life and mood: a pilot case-control study

2019 ◽  
pp. 19-25 ◽  
Author(s):  
Rathika Krishnasamy
Keyword(s):  
Quality Of Life ◽  
Qualitative Interviews ◽  
Social Function ◽  
Multidrug Resistant ◽  
Contact Precautions ◽  
Dialysis Vintage ◽  
Multidrug Resistant Organisms ◽  
And Gender ◽  
The Impact

Background: The rate of multidrug-resistant organisms (MDRO) colonisation in dialysis populations has increased over time. This study aimed to assess the effect of contact precautions and isolation on quality of life and mood for haemodialysis (HD) patients colonised with MDRO. Methods: Patients undergoing facility HD completed the Kidney Disease Quality of Life (KDQOL–SFTM), Beck Depression Inventory (BDI) and Personal Wellbeing-Index Adult (PWI-A). Patients colonised with MDRO were case-matched by age and gender with patients not colonised. Results: A total of 16 MDRO-colonised patients were matched with 16 controls. Groups were well matched for demographics and co-morbidities, other than a trend for older dialysis vintage in the MDRO group [7.2 years (interquartile range 4.6–10.0) compared to 3.2 (1.4–7.6) years, p=0.05]. Comparing MDRO-positive with negative patients, physical (30.5±10.7 vs. 34.6±7.3; p=0.2) and mental (46.5±11.2 vs. 48.5±12.5; p = 0.6) composite scores were not different between groups. The MDRO group reported poorer sleep quality (p=0.01) and sleep patterns (p=0.05), and lower social function (p=0.02). BDI scores were similar (MDRO-positive 10(3.5–21.0) vs. MDRO-negative 12(6.5–16.0), p=0.6). PWI-A scores were also similar in both groups; however, MDRO patients reported lower scores for “feeling safe”, p=0.03. Conclusion: While overall scores of quality of life and depression were similar between groups, the MDRO group reported poorer outcomes in sleep and social function. A larger cohort and qualitative interviews may give more detail of the impact of contact precautions and isolation on HD patients. The necessity for contact precautions for different MDRO needs consideration.

Reducing the Risks of the Financial Sector to Ensure Sustainable Growth of the Russian Еconomy

2019 ◽  
Vol 12 (3) ◽  
pp. 86-92
Author(s):  
T. I. Minina ◽  
V. V. Skalkin
Keyword(s):  
Economic Growth ◽  
Monetary Policy ◽  
Financial Sector ◽  
Developed Countries ◽  
Sustainable Growth ◽  
Necessary Condition ◽  
Real Sector ◽  
Financial Instruments ◽  
The Real ◽  
The Impact

Russia’s entry into the top five economies of the world depends, among other things, on the development of the financial sector, being a necessary condition for the economic growth of a developed macroeconomic and macro-financial system. The financial sector represents a system of relationships for the effective collection and distribution of economic resources, their deployment according to public demand, reducing the risk of overproduction and overheating of the economy.Therefore, the subject of the research is the financial sector of the Russian economy.The purpose of the research was to formulate an approach to alleviating the risks of increasing financial costs in the real sector of the economy by reducing the impact of endogenous risks expressed as financial asset “bubbles” using the experience of developed countries in the monetary policy.The paper analyzes a macroeconomic model applied to the financial sector. It is established that the economic growth is determined by the growth and, more important, the qualitative development of the financial sector, which leads to two phenomena: overproduction in the real sector and an increase in asset prices in the financial sector, with a debt load in both the real and financial sectors. This results in decreasing the interest rate of the mega-regulator to near-zero values. In this case, since the mechanisms of the conventional monetary policy do not work, the unconventional monetary policy is used when the mega-regulator buys out derivative financial instruments from systemically important institutions. As a conclusion, given deflationally low rates, it is proposed that the megaregulator should issue its own derivative financial instruments and place them in the financial market.

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