Impact of Assisted Reproductive Technology on Embryonic Health Screening Tests: A Case-Control Study

2020 ◽  
Vol In Press (In Press) ◽  
Author(s):  
Shirin Soltani ◽  
Akbar Karimi ◽  
Zahra Khashavi ◽  
Nasibeh Roozbeh
Keyword(s):  
Pregnant Women ◽  
First Trimester ◽  
Assisted Reproductive Techniques ◽  
Screening Tests ◽  
Control Group ◽  
Case Group ◽  
Second Trimester ◽  
Significant Difference ◽  
Reproductive Techniques ◽  
The Mean

Background: More than one million children throughout the world are born by using fertility techniques. In this process, human intervention and laboratory conditions may have an impact on the growth and development of the fetus. Objectives: The present study aimed to consider the effect of assisted reproductive techniques on the results of embryonic health screening tests. Methods: In this case-control study, among clients who went to the Infertility Center of the Ome Leila Hospital in Bandar Abbas Province, we selected 200 pregnant women who were impregnated via assisted reproductive techniques as the case group and 200 natural pregnant women as the control group by sample random sampling. Checklists were filled out and data analyzed by the SPSS version 21 and chi-square tests by using an interview with pregnant women and investigating the embryonic screening tests. Results: Most of the participants in the study were housewives and had primary infertility. Their BMI was normal. There was no significant difference between the final results of the embryonic screening test in the two groups at the first trimester (P > 0.05). However, in the second trimester, there was a significant difference between them. The positive results were higher in the case group in comparison with the control group (P = 0.001). The mean of all types of screening tests in the first trimester in both groups was not different, significantly (P < 0.05), although in the second trimester, the mean of all the testis, including BHCG (P = 0.006) and AFP (P = 0.018) in both case and control groups, was significantly different. The mean of BHCG and AFP was higher in the case group, while the mean of Estradiol and Inhibin, NB, and NT were not really different (P < 0.05). Conclusions: Our study showed that embryonic screening tests, particularly the BHCG and AFP tests, would be affected by applying the assisted reproductive techniques. For the couples who had a history of infertility and used reproductive methods, screening tests are essential in the first and second trimester.

scholarly journals Comparison of Salivary Alpha-Amylase, Sialic Acid, and pH in Pregnant and Nonpregnant Subjects

2021 ◽  
Author(s):  
Masoomeh Shirzaiy ◽  
Zohreh Dalirsani
Keyword(s):  
Sialic Acid ◽  
Pregnant Women ◽  
First Trimester ◽  
Control Group ◽  
Case Group ◽  
Third Trimester ◽  
The Third ◽  
Significant Difference ◽  
Salivary Ph ◽  
The Mean

Abstract Objectives During pregnancy, systemic physiological alterations lead to some changes in the oral cavity, which could prepare the mouth environment for oral and dental problems. This study was aimed to investigate salivary α-amylase, sialic acid levels, and pH levels in pregnant and nonpregnant females. Materials and Methods In this analytical, case–control study, unstimulated saliva samples were collected with spiting method from 35 pregnant women (case group) and 35 nonpregnant women (control group) and transferred to the laboratory to assess salivary α-amylase, sialic acid, and pH levels. Data were analyzed by SPSS (version: 19) software through statistical methods of independent t-test and analysis of variance. Results The mean sialic acid levels were 2.285 ± 1.230 mg/dL in pregnant and 2.744 ± 1.326 in nonpregnant women without any significant difference (p = 0.138). The mean salivary α-amylase concentrations were 2.461 ± 1.869 U/L and 2.439 ± 2.058 U/L, respectively, in pregnant and nonpregnant women, with no significant difference (p = 0.963).The mean salivary pH in nonpregnant women was significantly more than that in pregnant women (7.845 ± 0.430 and 6.868 ± 0.413, respectively) (p < 0.001). Also, the mean salivary pH levels in pregnant women were 7.474 ± 0.420 in the first trimester, 6.868 ± 0.413 in the second trimester, and 6.568 ± 0.387 in the third trimester, which were significantly different (p < 0.001). Conclusion Salivary sialic acid and α-amylase levels among pregnant women were no different from those of other subjects. During pregnancy, the salivary pH significantly reduced, and the mean salivary pH during pregnancy had a decreasing trend from the first trimester to the third trimester.

PERAN MAP, ROT, IMT DALAM SKRINING PREEKLAMPSIA DI INDONESIA

2021 ◽  
Vol 3 (4) ◽  
pp. 331
Author(s):  
Dwi Putri Rahayu Tampubolon ◽  
Lilik Herawati ◽  
Ernawati Ernawati
Keyword(s):  
Pregnant Women ◽  
Sampling Technique ◽  
First Trimester ◽  
Case Control ◽  
High Rate ◽  
Control Group ◽  
Case Group ◽  
Second Trimester ◽  
Chi Square ◽  
Consecutive Sampling

Abstrak Latar Belakang : Preeklampsia tetap menempati peringkat pertama sebagai penyebab tingginya Angka Kematian Ibu (AKI) di Surabaya dari tahun 2013-2017 sebesar 28.92 %. Tingginya angka preeklampsia bisa dicegah dengan dilakukannya skrining preeklampsia yang mudah dilakukan pada trimester I dan II yaitu dengan dilakukannya skrining Mean Arterial Presure (MAP), Roll Over Test (ROT), Indeks Masa Tubuh (IMT) di fasilitas kesehatan dasar. Tujuan dari penelitian ini untuk mengetahui hubungan antara Skrining Preeklampsia (MAP, ROT, IMT) yang dilakukan pada ibu hamil trimester I dan trimester II serta kejadian preeklampsia. Metode : Penelitian ini adalah penelitian Retrospektif, Case Control dengan sampel pada kelompok kasus yaitu pasien preeklampsia pada saat trimester I dan II yang dilakukan skrining preeklampsia sedangkan untuk kelompok kontrol, ibu hamil normal yang juga dilakukan skrining preeklampsia pada trimester I dan II. Hasil : Didapatkan besar sampel 189 ibu hamil dengan preeklampsia selama 1 tahun, pengambilan sampel dengan teknik consecutive sampling. Hasil pemeriksaan diperoleh pada kelompok kasus didapatkan pasien dengan MAP (+), ROT (+), IMT (+) berturut-turut adalah 43 (95.6 %), 18 (40 %) dan 18 (40 %), sedangkan pada kelompok kontrol diperoleh hasil 18 (40 %) sampel MAP (+), 26 (57.8 %) ROT (+), 5 (11.1 %) IMT (+). Hasil uji statistik Chi Square menunjukan adanya hubungan signifikan antara skrining MAP dan IMT dengan kejadian preeklampsia dengan nilai p berturut-turut (p 0.0001, OR = 32.250 dan p 0.002, OR = 5.333 ), namun tidak didapatkan hubungan antara skrining ROT dengan kejadian preeklampsia (p 0.092 OR = 0.487). Didapatkan hubungan ketiga skrining (MAP, ROT, IMT) dengan kejadian preeklampsia (p 0.001, OR 4.529). Kesimpulan : Pasien MAP (+) dan IMT (+) mempunyai resiko sebesar 32 kali dan 5 kali pada preeklampsia. Skrining ROT (+) tidak mempunyai hubungan dengan kejadian preeklampsia.AbstractBackground: Preeclampsia still ranks first as the cause of the high Maternal Mortality Rate (MMR) in Surabaya from 2013-2017 at 28.92%. The high rate of preeclampsia can be prevented by conducting pre-eclampsia screening that is easy to do in the first and second trimesters by doing Mean Arterial Presure (MAP) screening, Roll Over Test (ROT), Body Mass Index (BMI) in basic health facilities. The purpose of this study was to determine the relationship between Preeclampsia Screening (MAP, ROT, BMI) performed in first trimester and second trimester pregnant women and the incidence of preeclampsia. Methods : This study was a retrospective study, case control with samples in the case group, namely preeclampsia patients during the first and second trimesters of preeclampsia screening, while for the control group, normal pregnant women who were also screened for preeclampsia in the first and second trimester. Results There was a sample of 189 pregnant women with preeclampsia for 1 year, taking samples by consecutive sampling technique. The results of the examination were obtained in the case group obtained patients with MAP (+), ROT (+), BMI (+) respectively 43 (95.6%), 18 (40%) and 18 (40%), while in the control group obtained results of 18 (40%) samples of MAP (+), 26 (57.8%) ROT (+), 5 (11.1%) BMI (+). The Chi Square statistical test results showed a significant relationship between MAP and BMI screening with the incidence of preeclampsia with p values in a row (p 0.0001, OR = 32,250 and p 0.002, OR = 5,333), but no association between ROT screening and the incidence of preeclampsia ( p 0.092 OR = 0.487). Obtained the third screening relationship (MAP, ROT, BMI) with the incidence of preeclampsia (p 0.001, OR 4,529). Conclusion: MAP (+) and BMI (+) patients have 32 times and 5 times higher risk of preeclampsia. Screening for ROT (+) has no relationship with the incidence of preeclampsia.

scholarly journals Appraisal of A1c% level in healthy Sudanese pregnant women in reference to body mass index

2019 ◽  
Vol 8 (5) ◽  
pp. 1835
Author(s):  
Abdelgadir Ali Elmugadam ◽  
Marwan Ismail ◽  
Abdelgadir Eltom
Keyword(s):  
Body Mass Index ◽  
Pregnant Women ◽  
Body Mass ◽  
First Trimester ◽  
The Body ◽  
Control Group ◽  
Third Trimester ◽  
Significant Difference ◽  
The Mean ◽  
Mean Concentration

Background: Pregnancy is a major endocrine event in the female lifespan, involving wide-ranged and often dramatic changes in the metabolism of various hormones. Cross sectional, case control, analytical quantitative study was conducted in Sudan, Khartoum state in Yastabsheron obstetric hospital during the period from March to August 2011. Analytical and statistical methods were applied to measure the concentration of A1c% in healthy pregnant women as well as in healthy non-pregnant women to assess the difference in the results.Methods: Blood samples were taken from a total of 90 healthy pregnant women (case group) and 30 healthy non-pregnant women (control group), then samples were analyzed for A1c% by using affinity chromatography technique, and results were recorded in addition to their age, body mass index and the number of pregnancies.Results: showed that, the mean concentration of the A1c% in cases group was (4.407±1.054%) in first trimester, (4.797±0.631) % in second trimester and (4.833±0.626) % in third trimester, and (5.670±0.471%) in control group with a P value of 0.00, indicating the highly significant difference between the two groups. Others finding showed that the mean concentration of A1c% of the first trimester is lower than that of the second and third trimesters, also there was no significant difference between the mean concentration of the second and third trimester. A significant weak positive correlation between A1c% concentration with body mass index and the age of pregnant women.Conclusions: Healthy normal pregnant women have lower A1c% concentrations than non-pregnant women which can be impute to the reduce in plasma glucose values and to the shortened erythrocyte life span that can occur during pregnancy. The body mass index and age affect the concentration of A1c% c, but it is not affected by gravida.

scholarly journals The association between serum betahuman Chorionic gonadotropin and Preeclampsia

2015 ◽  
Vol 23 (1) ◽  
pp. 89-93 ◽  
Author(s):  
Zinat Begum ◽  
Iffat Ara ◽  
Shaorin Tanira ◽  
Kashfia Ahmed Keya
Keyword(s):  
Pregnant Women ◽  
Severe Preeclampsia ◽  
Control Group ◽  
Case Group ◽  
Control Groups ◽  
Medical College ◽  
Significant Difference ◽  
Blood Pressures ◽  
The Mean ◽  
And Control

Background: Exact aetiology of this potentially fatal disorder remains poorly understood. A number of theories have been put forward where different biochemical markers have been implicated in the causal association of preeclampsia. This study was intended to find the association between serum b-hCG level and preclampsia Methods: This cross-sectional, case-control study was conducted on 74 pregnant women with preeclampsia (cases) who were admitted in the Eclampsia ward of Dhaka Medical College Hospital, Dhaka between January and July of 2013. A total of 76 normotensive pregnant women were also taken from the Obstetrics & Gynaecology Out-patient Department of the same hospital as control. The study subjects were selected on the basis of predefined eligibility criteria. The serum levels of b-hCG were compared between case and control groups as well as between mild and severe preeclampsia. Result: The case and control groups were almost similar in terms of all the baseline demographic and obstetric characteristics except past history of PET which was significantly higher in the former group than that in the latter group. Majority (97.1%) of the cases had severe hypertension (74.3%) with mean systolic and diastolic blood pressures being 162.6 and 110.8 mmHg respectively. The mean serum ?-hCG was much higher in the case group than that in the control group (p<0.001). The mean serum ?-hCG was the highest in severe preeclampsia and the lowest in the control group, while that in mild preeclampsia lie in between the two (p<0.001). The serum ?-hCG exhibits a significantly linear correlation with systolic and diastolic blood pressures (p<0.001 respectively). Conclusion: There was a significant difference between the ?-hCG level in the preeclamptic women compared to the normotensive pregnant women and the severity of preeclamsia increases with further rise of ?-hCG level. DOI: http://dx.doi.org/10.3329/jdmc.v23i1.22701 J Dhaka Medical College, Vol. 23, No.1, April, 2014, Page 89-93

scholarly journals Estimating Rate of Insulin Resistance in Patients with Preeclampsia Using HOMA-IR Index and Comparison with Nonpreeclampsia Pregnant Women

2014 ◽  
Vol 2014 ◽  
pp. 1-6 ◽  
Author(s):  
Farideh Rezaei Abhari ◽  
Maryam Ghanbari Andarieh ◽  
Asadollah Farokhfar ◽  
Soleiman Ahmady
Keyword(s):  
Insulin Resistance ◽  
Pregnant Women ◽  
Fasting Blood Glucose ◽  
First Trimester ◽  
Control Group ◽  
Case Group ◽  
Third Trimester ◽  
Significant Difference ◽  
Diagnosis Criteria ◽  
And Control

Women with preeclampsia, independent of obesity and glucose intolerance, exhibit insulin resistance during pregnancy. The purpose of the present study is to determine whether early diagnosis of insulin resistance during pregnancy can predict preeclampsia. Through a case-control study, 675 pregnant women were selected and their first trimester blood was taken. Their fasting blood glucose and insulin were also measured after diagnosis of preeclampsia by 20 weeks of pregnancy. Based on the experiments conducted on 675 women who were 20 weeks past their pregnancy, 375 cases with preeclampsia were selected and assigned to the case group. 35 other pregnant women were put in the control group. Diagnosis criteria for the participants included blood pressure above 140/90 and proteinuria above 300 mg or above +1. Both groups were matched according to age, parity, gestational age, and BMI. Homa-Irand rate of insulin resistance was calculated by HOMA-IR and patients were followed up. Homeostatic model assessments (HOMA-IR) revealed that the average insulin resistance increased during pregnancy among both the case and control groups. There was a significant difference between insulin resistance of these two groups in both first trimester and third trimester and after developing preeclampsia (P< 0.001,P= 0.021). Insulin-resistance of the group with preeclampsia was higher in first trimester prior to diagnosis as well as the third trimester after diagnosis compared to natural pregnancy under similar conditions. Measurement of insulin resistance in first trimester may be useful in predicting the risk of preeclampsia.

scholarly journals The Effect of Down Syndrome Biochemical Markers on Predicting Severity of Preeclampsia

2020 ◽  
Author(s):  
AYSE OZBAN
Keyword(s):  
Down Syndrome ◽  
Pregnant Women ◽  
Biochemical Markers ◽  
First Trimester ◽  
Maternal Serum ◽  
Screening Tests ◽  
Second Trimester ◽  
Study Results ◽  
Second Trimester Screening ◽  
Trimester Screening

Abstract Objective: This study aims to determine whether it is possible to predict preeclampsia by comparing postpartum results and test results of the pregnant women diagnosed with preeclampsia, whose first and/or second trimester screening tests were accessible, and to demonstrate the predictability of severity and week of onset.Background: 204 patients underwent renal transplantation in our center and 84 of them were female. Five of our patients (one of them had two births) gave birth to a total of 6 pregnancies.Method: 135 patients were diagnosed with preeclampsia and their first and/or second trimester screening tests were accessible, and 366 control participants gave birth to a healthy baby between 37-41 weeks after standard follow-up period for pregnancy and their screening tests were also accessible.Results: The study results show that the first trimester maternal serum PAPP-A level is significantly low in preeclamptic pregnant women, and that the second trimester maternal serum AFP and hCG levels are significantly high and uE3 levels are significantly low The results also suggest that the first and second trimester Down syndrome biochemical markers can be used in preeclampsia screening.Conclusion: Among these markers, uE3 is the parameter which affects the possibility of preeclampsia the most. However, the first and second trimester Down syndrome biochemical markers are not effective in predicting the severity and onset week of preeclampsia.

scholarly journals Effects of human chorionic gonadotropin intrauterine injection on oocyte retrieval day on assisted reproductive techniques outcomes: An RCT

2021 ◽  
pp. 773-780
Author(s):  
Robabe Hosseinisadat ◽  
Lida Saeed ◽  
Sareh Ashourzadeh ◽  
Sedigheh Safar Heidari ◽  
Victoria Habibzadeh
Keyword(s):  
Chorionic Gonadotropin ◽  
Human Chorionic Gonadotropin ◽  
Oocyte Retrieval ◽  
Pregnancy Rates ◽  
Clinical Pregnancy ◽  
Assisted Reproductive Techniques ◽  
Control Group ◽  
Case Group ◽  
Reproductive Techniques ◽  
Clinical Pregnancy Rates

Background: Several mediators play an important role in implantation. One of these mediators is human chorionic gonadotropin (HCG). Objective: To evaluate the effects of HCG intrauterine injection on the day of oocyte retrieval on the result of assisted reproductive techniques (ART). Materials and Methods: In this randomized clinical trial study, 126 women who were referred to Afzalipour Infertility Center between December 2018 to December 2019 undergoing in vitro fertilization/intracytoplasmic sperm injection cycles were enrolled and assigned to two groups of: a case (n = 62) and a control group (n = 64). The protocols for both groups were the same; except that the case group was injected with the protocols for both groups were the same, except that the case group was injected with 1000 IU of HCG into uterine cavity following the oocyte puncture, while no medication was administered to the control group. The implantation rate, chemical pregnancy, clinical pregnancy, and abortion rates were compared between the two groups. Results: Positive chemical pregnancy was seen in 15 (27.3%) cases of the case group and 14 (25.5%) of the control group. No significant difference was seen in the chemical and clinical pregnancy rates between the groups. The abortion rate was higher in the control group but that was not significant. Conclusion: A 1000 IU of HCG intrauterine injection after oocyte retrieval does not improve implantation, chemical or clinical pregnancy rates in ART cycles. Further studies are needed to clearly understand the role of HCG intrauterine injection in the day of oocyte retrieval in ART outcomes. Key words: Oocyte retrieval, Chorionic gonadotropin, Pregnancy, Assisted reproductive techniques.

The effect of ear acupressure medicine at the “Shen Men” point on the nausea and vomiting during pregnancy

2021 ◽  
Vol 15 (5) ◽  
pp. 1774-1779
Author(s):  
Sanaz Nehbandani ◽  
Hajar Salehi ◽  
Khadije Rezaie Keikhaie ◽  
Hossein Rashki Ghalenow ◽  
Fatemeh Mirzaie ◽  
...  
Keyword(s):  
Pregnant Women ◽  
Gestational Age ◽  
Intervention Group ◽  
Nausea And Vomiting ◽  
Control Group ◽  
Health Clinics ◽  
Significant Difference ◽  
Quasi Experimental ◽  
The Mean ◽  
The Difference

Introduction & Objective: Nausea and vomiting during pregnancy is one of the most common gastrointestinal disorders that more than 85% of pregnant women experience. However, controlling and treating this complication is still one of the most important issues in antenatal care. Therefore, the aim of this study was to investigate the effect of ear acupressure at Shen Men point on relieving nausea, vomiting and retching during pregnancy. Materials and Methods: In this quasi-experimental study, 100 pregnant women with a gestational age of less than 16 weeks attending the health clinics of Zabol city during 2019-2020 were studied in two control and intervention groups (n = 50 in each group). The samples in the intervention group were trained to apply pressure on their ears’ Shen Men point with the thumb for three minutes three times a day (morning, noon, and night), for a duration of one month. At the end of second and fourth weeks, the data were collected using the Rhodes index form and then, were analyzed by SPSS software version 22. Results: According to the results, there was no significant difference between the two groups in terms of age, gestational age, occupation and education. The difference in the mean scores of nausea, vomiting and retching was not statistically significant between the control and intervention groups before the study. But four weeks after the study, a significant difference was observed in the mean scores of vomiting, nausea and retching between the two groups, so that the mean scores of vomiting, nausea and retching were significantly lower in the intervention group than in the control group. Conclusion: The ear acupressure medicine at the Shen men point can be used as a non-invasive, safe and inexpensive method to relieve nausea, vomiting and retching during pregnancy. Keywords: Acupressure medicine, Shen Men, Vomiting, Pregnancy, Nausea, Retching, Rhodosis

Maternal Serum Haptoglobin Levels as a Marker of Preterm Premature Rupture of Membranes

2020 ◽  
Author(s):  
Gul Nihal Buyuk ◽  
Z.Asli Oskovi-Kaplan ◽  
Huseyin Durukan
Keyword(s):  
Pregnant Women ◽  
Maternal Serum ◽  
Control Group ◽  
Premature Rupture ◽  
Roc Curve Analysis ◽  
Membrane Rupture ◽  
Preterm Premature Rupture ◽  
Serum Haptoglobin ◽  
Significant Difference ◽  
The Mean

Abstract Objective We aimed to investigate the prognostic value of maternal serum haptoglobin levels in patients presenting with preterm premature rupture of fetal membranes (PPROM) during the second and the third trimesters of pregnancy. Methods In this case control study, 60 patients were recruited (30 pregnant women with PPROM between 26–34 weeks of gestation and 30 healthy, gestational-age-matched pregnant women without PPROM). White blood cell count (WBC), interleukin 6 (IL-6), C-reactive protein (CRP), sedimentation rate, and haptoglobin levels were measured. Results The mean age, gestational week, gravida, and parity of the 2 groups were statistically comparable (P>0.001). There was a statistically significant difference between the 2 groups in terms of haptoglobin values (p<0.001). The mean haptoglobin level was 115.5+33.1(mg/dl) in the PPROM group and 66.5+42.6 (mg/dl) in the control group. ROC curve analysis was performed to determine whether the level of haptoglobin alone could diagnose PPROM as an independent marker. It was shown that the level of 94.5 mg/dL for haptoglobin could indicate the diagnosis of PPROM with 80% sensitivity and specificity Conclusion Maternal serum haptoglobin levels may be a diagnostic marker for suspected PPROM cases when membrane rupture diagnosis is not accurate based on physical examination and other diagnostic tests.

scholarly journals Ultrasound elastography capabilities in studying uterine cerviх state in pregnant women of high-risk group in the first trimester of pregnancy

2016 ◽  
Vol 97 (4) ◽  
pp. 656-661
Author(s):  
M G Tukhbatullin ◽  
K V Yanakova
Keyword(s):  
High Risk ◽  
Pregnant Women ◽  
Chromosomal Abnormality ◽  
Chromosomal Abnormalities ◽  
Ultrasound Examination ◽  
Risk Group ◽  
First Trimester ◽  
High Risk Group ◽  
Control Group ◽  
Significant Difference

Aim. To study capabilities of quantitative elastographic study to assess the elasticity of the uterine cervix in women with a fetal chromosomal abnormality in the first trimester of pregnancy.Methods. 230 pregnant women of high-risk group at 11-13.6 weeks of pregnancy (parietal-coccygeal length 45-84 mm) were included in this study. The first group consisted of 213 women without fetal pathology. The second group included 17 women, in whose fetuses different chromosomal abnormalities were detected. In ultrasound examination of pregnant women in the I trimester of pregnancy, in addition to standard methods of examination, quantitative cervical elastography was performed.Results. According to results of quantitative elastography in 14 (82.35%) out of 17 pregnant women (second group) one or another degree of the cervical tissue softening was found, and 3 (17.64%) pregnant women with fetal chromosomal pathology had stiff cervix (all 3 cases with Down syndrome). In the control group in 10 (4.7%) of 213 pregnant women relatively soft cervix was identified, and in 203 (95.3%) women cervical density was higher than the myometrial density. A statistically significant difference between the indices of SWE-Ratio in groups was revealed. Quantitative elastography, as a diagnostic test predicting the risk of miscarriage due to chromosomal abnormalities, has a high sensitivity (84.38%) and even higher specificity (95.26%) of negative predictive value 97.57%.Conclusion. Quantitative elastography reveals a significant decrease in the cervical elasticity (softening) in pregnant women with fetal chromosomal abnormality in the I trimester of pregnancy, which allows us to recommend this method of ultrasound examination as an additional marker for early diagnosis of miscarriage due to fetal chromosomal abnormality.

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