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Year : 2016 | Volume : 4 | Issue : 2 | Page : 80 - 84  


Original Articles
Enhancing survival of Young Infants to improve Infant Mortality Rate

Sarfaraz Ahmed1, Habib G Pathan2

1Consultant Pediatrician, Nanded Children’s Hospital, Nanded

2Associate Professor of Pediatrics, Malla Reddy Medical College for Women, Hyderabad

Corresponding Author:

Dr. Habib G Pathan

Email: drphabib@yahoo.co.in

 

Abstract:

Background: About 40% of the estimated 10.8 million annual child deaths worldwide occur in first two months of life. Besides mortality, infants experience at least five to six episodes of illnesses per year. Despite having the problem well defined there is no consistent evaluations and management approach to infants aged less than three months.

Objective: To quantify the nature and burden of illnesses in the first months of life.

Methods: This Prospective study was conducted among all consecutive subjects between 8 days to 90 days of age admitted during this period were subjects of this study. They underwent through a standardized set of enquiry, clinical examination and investigations. A precoded standardized assessment form was used for data recording. The study subjects were diagnosed and managed according to the protocol of treating unit under the supervision of the senior faculty.

Results: The most common clinical signs was chest indrawing- 98 (64.9%), followed by tachycardia- 65 (44.4%). Following factors may have a higher risk of death: wasting, rapid breathing and respiratory distress, slow / irregular respiration, diarrhea, dehydration, low body temperature with or without impaired perfusion on admission and cyanosis.

Conclusion: Presence of risk factors identified in this study should warrant immediate and appropriate measures.

Key words: Mortality, Morbidity, Infants

INTRODUCTION:

Leitmotif of our study is “the young infant”. About 40% of the estimated 10.8 million annual child deaths worldwide occur in first two months of life 1. Infant mortality rate in India was 58 per 1000 live births (2004) 2 and deaths in first year account for 18.7% of total deaths 3. Although the infant mortality rate, in India, has dropped from 129 per 1000 live births in 1970 to 58 per 1000 live births, it is still very high compared to developed countries which are now mostly in the range of 3-7 per 1000 live births 4. In developing countries about 80% of infant deaths occur in first six months of life and two-third of post-neonatal deaths occur before six months of life. In India, there are about 1.8 million deaths under the age of one year, out of these, about 1.2 million babies die in first month of life, despite underreporting 5. For a given nutritional status, the younger the child, the greater is the risk of death.

Besides mortality, infants experience at least five to six episodes of illnesses per year. Illnesses during this period if not managed appropriately, have considerable long-term morbidity and sequelae including neurological impairment and perhaps the origin of some late childhood or adult chronic diseases 6. Blindness, hearing defects, developmental delay, failure to thrive, mental retardation and behavioral problems are all consequences of inadequate care and attention during this critical age. Despite having the problem well defined there is no consistent evaluations and management approach to infants aged less than three months. Several strategies / protocols have been reported, compared and retested in pediatric literature but no protocol has been universally accepted. WHO has recently developed a case management strategy to reduce mortality due to common childhood disorders in developing countries through an integrated interventional approach as a part of IMCI strategy. WHO has targeted young infant population through this strategy and separate guidelines have been developed for children less than two months age that are currently being implemented in developing countries 7.

Main purpose of this study is to quantify the nature and burden of illnesses in the first months of life.

 

MATERIAL AND METHODS

This Prospective study was conducted at the Pediatric ward, Sassoon General Hospital, Pune between January to June 2007. All consecutive subjects between 8 days to 90 days of age admitted during this period were subjects of this study. All enrolled cases underwent through a standardized set of enquiry, clinical examination and investigations. A precoded standardized assessment form was used for data recording (annexure). Demographic information collected included age (in completed weeks), sex, weight and presence of wasting. Information regarding birth weight, size at birth; as perceived by mother, immunization status, feeding pattern, failure of lactation, HIV status of mother and whether required hospital care at birth was collected. Detailed clinical examination was performed for each of the subjects and findings were recorded as either presence or absence of each clinical sign. To ensure consistency in assessment, preset guidelines were used to define a particular sign : high temperature – temperature > 38 0 C, low temperature – temperature < 35 0 C, tachycardia – heart rate > 160 / min, tachypnea – respiratory rate > 50 / min, slow / irregular respiration, chest indrawing – subcostal / intercostal retractions, shock – weak or impalpable pulses in presence of cold peripheries or mottling, dehydration – dryness of oral mucosa / sunken eyes / decreased skin turgor, altered sensorium – excessive irritability or sleepiness, edema – fullness of dorsum of feet or puffiness of face, hepatomegaly – palpable liver > 2 cm below costal margin, splenomegaly – palpable spleen, rapid breathing-mother’s perception of increased abdominal movements. Cyanosis, jaundice, pallor, tone, murmur, rhonchi, crepitations, dysmorphic features and other signs were recorded on the basis of assessment by the attending clinician.

Investigations performed routinely were complete blood count, venous blood gas analysis (in 124 subjects) and chest x-ray (in 138 subjects). Hemoglobin levels were categorized as : < 7 gm / dl, 7-10 gm / dl and > 10 gm / dl. Following abnormalities were defined on complete blood count (CBC) : leucocytosis - total WBC count > 15,000/mm3 , leucopenia - total WBC count < 5,000/mm3 , neutrophilia - absolute neutrophill count > 10,000/mm3 , neutropenia - absolute neutrophill count < 1,500/mm3 , eosinophilia – absolute eosinophill count > 500/mm3, lymphocytosis - absolute lymphocyte count > 6,000/mm3 , monocytosis - absolute monocyte count > 500/mm3 , bandemia - presence of band   cells 8, 9.

Based on venous blood gas analysis, pH was categorized into: < 7.3 and ≥ 7.3,   pCO2 was categorized into : < 45 mm Hg and ≥ 45 mm Hg and base deficit was categorized into : £ 5, 6-14 and ³ 15. Chest x-ray findings recorded were normal, lobar consolidation, bronchiolitis              (hyperinflation) and cardiomegaly (cardiothoracic ratio > 0.5).

The study subjects were diagnosed and managed according to the protocol of treating unit under the supervision of the senior faculty. Oxygen, intragastric feeds and intropes were used as per existing guidelines. Subjects initially received antibiotics – chloramphenicol, amikacin and piperacillin in infants aged more than 4 weeks and ampicillin and gentamycin in infants aged 4 weeks or less. Subjects not responding to above antibiotics, received second line antibiotics that included amoxicillin – clavulanate, cefepime, piperacillin – tazobactum and meropenam.

 

RESULTS

Maximum subjects were in the age group of 8 days to 4 weeks 59 (39%). Males were more than females i.e. 86 (57%) vs. 65 (43%) that were females. Weight on admission was < 2.5 kg in 64 (42.4%). Wasting was observed in 67 (44.4%). 63 (41.7%) infants had history of hospitalization at birth. The most common clinical signs was chest indrawing- 98 (64.9%), followed by tachycardia- 65 (44.4%).

55% had hemoglobin levels < 7 mg/dl Leucocytosis was seen in 57 (38.3%), neutropenia- 16 (10.7%), band cells / toxic granules- 31 (20.8%), lymphocytosis- 70 (47%), eosinophilia- 35(23.5%) and monocytosis- 36 (24.3%). Evidence of sepsis on CBC was found in 62 (41.6%). Positive isolate on blood culture was found in 18 out of 45 blood cultures that were performed. Observations on blood gas analysis (of total 124) were : pH < 7.3- 78 (62.9%), pH ≥7.3- 46(37.1%), CO2 retention (i.e., pCO2 ³ 45 mm Hg)- 36 (29%), base deficit < 5- 30(24.2%), 5 – 15- 61(49.2%) and base deficit ³ 15- 33 (26.6%).

Table 1: Distribution of subjects according to indications for hospitalization

Parameter

Yes

No

Cough/cold

71 (47)

80 (53)

Rapid breathing (mother’s perception)

79 (52.3)

72 (47.7)

Chest in drawing

98 (64.9)

53 (35.1)

Tachypnea

95 (62.9)

56 (37.1)

Slow / irregular respiration

25 (16.6)

126 (83.4)

Poor feeding

85 (56.3)

66 (43.7)

Convulsions

12 (7.9)

139 (92.1)

Diarrhea

20 (13.2)

131 (86.8)

Vomiting

20 (13.2)

131 (86.8)

Jaundice

11 (7.3)

140 (92.7)

 

Table 2: Distribution of subjects according to clinical signs

Parameter

Yes

No

Tachycardia

67 (44.4)

84 (55.6)

Signs of shock

32 (21.2)

119 (78.8)

Altered sensorium

30 (19.9)

121 (80.1)

Dehydration

13 (8.6)

138 (91.4)

Cyanosis

19 (12.6)

132 (87.4)

Edema

15 (9.9)

136 (90.1)

Murmur

25 (16.6)

126 (83.4)

Hepatomegaly

45 (29.8)

106 (70.2)

Splenomegaly

16 (10.6)

135 (89.4)

Dysmorphism/congenital anomalies

8 (5.3)

143 (94.7)

 

Table 3: Investigation results in the subjects

Parameter

Yes

No

Anemia

117 (78.5)

32 (21.5)

Sepsis

62 (41.6)

87 (58.4)

Leucocytosis

57 (38.3)

92 (61.7)

Neutrophilia

41 (27.5)

108 (72.5)

Leucopenia

9 (6)

140 (94)

Neutropenia

16 (10.7)

133 (89.3)

Bandemia/toxic granules

31 (20.8)

118 (79.2)

Lymphocytosis

70 (47)

79 (53)

Eosionophilia

35 (23.5)

144 (76.5)

Monocytosis

36 (24.2)

113 (75.8)

 

Table 4: Frequency Distribution–pH on VBG (No = 124)

Parameter

Number

Percentage

< 7.3

78

62.9

> 7.3

46

37.1

Table 5: Frequency Distribution–pCO2 in mm Hg on VBG (No = 124)

Parameter

Number

Percentage

< 45

38

71.0

> 45

36

29.0

TABLE 6: Frequency Distribution – Base deficit on VBG (No = 124)

Parameter

Number

Percentage

< 5

30

24.2

6-14

61

49.2

> 15

33

26.6

 

DISCUSSION

Past few decades have witnessed a major decline in ‘under five mortality’, majority of which has occurred in older infants and children, thanks to the interventions like promotion of oral rehydration solution, acute respiratory infections control programme and widespread immunization against vaccine preventable diseases. This leaves the target population of ‘young infants’ that needs to be addressed. The WHO has targeted this group of population by developing IMCI strategy. Separate guidelines were formulated for infants aged 7 days to 2 months. Recently, this programme has been changed to IMNCI to incorporate early neonatal period i,e., less than 7 days, which is still in a stage of evolution 7. Whereas birth asphyxia and severe prematurity are likely to be major causes of death in first week of life, serious bacterial infections are responsible for a greater proportion of mortality as infancy progresses 10, 11, 12. Morbidity and mortality in infants aged less than 7 days are governed primarily by the level of antenatal and obstetric care and are not likely to be significantly affected by the above interventions. Inclusion of early neonatal period would mean focusing on these antenatal and perinatal aspects of maternal care.

Hospitalization at birth:

Hospital care at birth was required in 41.7% of our babies for various reasons ranging from simple LBW care to severe sepsis and exchange transfusions. Risk among babies hospitalized at birth came close to have a higher risk of death. OR:1.94; CI (0.90-4.17). Various reasons described by proponents of early discharges in developing countries are less bed capacity at public hospitals, maternal illness and family problems like nuclear family with other sibling at home, financial difficulties and inconvenience to families from remote areas. In developed countries they are mainly hospital stay and reimbursement, bonding and attachment of mother and baby. Concerns of early discharges include increased rehospitalization and increased parental anxiety, inadequate establishment of breast feeding and lactation failure.

  1. J. Oddie and coworkers in their case cohort study in UK observed that infants less than 2.5 kg at birth and first born infants were less likely while women from more deprived areas were more likely to be discharged early. Risk of readmission was higher in babies 35-37 weeks and less than 2.5 kg at birth and it also varied significantly with hospital of birth but not with timing of discharge 13. Patricia J and coworkers in a population based study at Manitoba observed that risk of readmission was higher in infants who were born preterm, who were of lowest income quintiles, who resided in remote areas, whose mothers age was 17- 19 years (younger) and who were born by caesarian section. Respiratory illness was the leading cause of readmissions 14. G. J. Escobar observed that risk of rehospitalization was higher in SGA and male gender, with jaundice being the most common reason 15. Piyush Gupta and co-workers found that discharges were primarily governed by maternal indications. Discharge within 48 hours of birth was associated with higher risk of readmission and jaundice and feeding problem were the most frequent causes for readmissions. All jaundiced babies received phototherapy, none received exchange transfusion and 7 cases were treated as sepsis and discharged 16. We have found similar results among rehospitalized infants. RD and poor feeding were common among babies rehospitalized. 9 babies were readmitted with jaundice beyond 7 days age, 5 of these were LBW / prematurely born while 4 had suspected sepsis. Failure of lactation is also common among mothers whose babies are prematurely discharged. Considering all these possibilities the policy at our NICU was to discharge premature babies at post conception age of 35 weeks. During this period the babies were kept under vigilance for any ominous signs. Sick and LBW babies were offered enteral feeding until they were able to take adequate feeds at breast. All babies were kept in a warm and conducive environment. Mothers were counseled for breast feeding and proper home care of babies before their babies were discharged. Apparently fewer babies discharged from our hospital were readmitted.

Clinical features:

Poor feeding, respiratory distress, fever and cough / cold were the commoner presentations for which the subjects were admitted. These were followed by failure to gain weight, slow / irregular breathing, diarrhea, vomiting, convulsions and jaundice. These observations were broadly compatible with previous such studies. Duke’s study differed in the number of presumed malaria cases for high endemicity of malaria in Papua New Guinea and for non-availability of routine blood slides and rapid tests for malaria17. The contribution of jaundice and tetanus to morbidity was higher in the study at district hospital by M. English, et al. in contrast to our study10. Fever was the most common symptom observed in 70% of infants in another study on young infants presented by M English, et al. 18.   Sepsis and blood culture:

The rate of SBI reported by Bonadio WA, Smith DS and Sabnis S in febrile infants aged 8 to 12 weeks was 9.3% 19. Hsiao AL and co-workers found it to be 10.3% in older ( 57 – 180 days)febrile infants 20. V. Gajdos observed SBI in 25% in his study on 315 consecutive consultations of febrile infants less than 3 months 21. Virendra Kumar, et al. noted SBI in 36% in their hospital based study on infants up to 8 weeks of age admitted with suspected sepsis 22.

Increasing survival among ELBW babies and the relative immunodeficiency that persists into early infancy compounded by the high risk of hospital acquired infections, contribute to the high occurrence of sepsis in this age group. Over the years, the epidemiology of pathogens causing neonatal and early infant infections has changed. Whereas E. coli, group B Streptococci are major recognized pathogens in early neonatal period, other pathogens assume greater importance after this period. Pneumococcus is now known to be the most common organism causing trivial to life threatening illnesses in infants worldwide, while Staphylococci are more common in nosocomial infections.

In WHO study on etiology of SBI, Streptococcus Pneumoniae was the most common isolate, particularly after one week of age. During the first months of life, Staphylococci, S. pyogens and E. coli were the most common organisms isolated from blood culture. E.coli and gram negative organisms were more common in neonatal period, especially in younger than 7 days age group. Salmonella were more likely to be isolated in malnourished babies. Mortality was highest in infants with E.coli   infections 23. Data on bacterial isolates in study conducted by M. English, et al. were in broad agreement with WHO multicentric study 10. Virendra Kumar observed that the commonest isolate on culture was Klebsiella 22. A.S.M. Nawshaduddin and colleagues in their study on profile of neonatal septicemia at a tertiary center at Dhaka found that majority (70%) of the culture isolates were E.coli and Klebsiella 24. Group B streptococci and S. Pneumoniae are known to be the most common in developed countries. Richard G and co-workers discovered that group B Streptococci and E.coli were the most commonly isolated organisms in blood of febrile infants aged less than three months 25. Blood culture could be performed in 45, with positive isolate in a high proportion of 18 subjects. The pattern of blood culture isolates in our study was : E.coli – 4, Staphylococcal species – 3, Streptococci – 1, Acinetobactor – 1, Klebsiella – 1, Pseudomonas – 1, Alcaligens – 1, Candida –1, Trichosporon – 1 and contaminant – 3. Nearly half of our patients had evidence of infection.

Complete blood count:

Complete blood count and blood gas analysis in addition to clinical evaluation can be useful tools in assessing sepsis and shock. It was possible to monitor these parameters at our center without much time delay.

CBC has two different facets. One is sepsis, indicated by leucocytosis, neutropenia, toxic granules, band cells and monocytosis. The other include abnormalities such as eosinophilia and lymphocytosis. The percentage of babies having lymphocytosis in our study was striking 47%, while, eosinophilia was seen in 23.5%. Both these abnormalities probably reflect reactive, viral, chlamydial infection or whooping cough but may not correlate with septicemia. Past studies have established the relationship between WBC count, in association with other parameters, and septicemia 26, 27, 25. Virendra Kumar and Sunit Singhi evaluated the parameters that can be used to predict SBI in infants aged less than two months. They found that abnormal WBC count was useful while presence of toxic granules was the most sensitive and single criteria with a negative predictive value of 95% for SBI 22. Nathan Kuppermann, et al. reported that band cell count in the peripheral blood smear does not routinely help to distinguish between bacterial and viral infections 28. Leucocytosis, neutropenia and band cells were observed in 38%, 10% and 20% respectively, out of which only presence of band cells had a significant risk for death. Hemoglobin values less than 10 gm / dl were found in 117 infants, majority in those aged more than 4 weeks. Anemia in these babies should be interpreted carefully in view of the physiological nadir in hemoglobin values, that is known to occur at this age. Severe anemia, hemoglobin less than 7 gm / dl however, were observed in 35 subjects. Our transfusion policy for babies with low hemoglobin levels, unless in CCF, was conservative. Two babies were transfused. Neither hemoglobin value less than 10 gm / dl nor less than 7 gm / dl were associated with higher risk of death.

Blood gas analysis:

The practical problems faced when arterial blood was used for assessment of critically ill babies were technical difficulties in obtaining arterial samples and hematoma formation. Gennis PR, et al highlighted the usefulness of peripheral venous blood in assessing acutely ill patients 29. D Yildizdas and colleagues simultaneously obtained capillary, venous and arterial blood gases of patients in pediatric intensive care unit. They concluded that there was a significant correlation between pH, pCO2, pO2, BE and HCO3 values among arterial, venous and capillary blood gases except for poor correlation of pO2 in presence of hypotension 30. We relied on venous blood for pH and BE monitoring since venous catheters were secured in subjects for obtaining blood samples and as an access for intravenous medications and non – invasive methods like pulse oximeter for monitoring of SPO2. Blood pH and base deficit may be better markers of hypoperfusion and tissue hypoxemia leading to lactic acidosis. Both PH < 7.3 and BE > 15 were associated with higher risk of death, which again supports the usefulness of these parameters in intensive case units.

 

CONCLUSION:

Following factors may have a higher risk of death: wasting, rapid breathing and respiratory distress, slow / irregular respiration, diarrhea, dehydration, low body temperature with or without impaired perfusion on admission and cyanosis. Laboratory parameters like blood pH less than 7.3 and base deficit 15 or more and CBC picture suggestive of sepsis especially the presence of band cells may have higher risk of death. Presence of these features and should warrant immediate and appropriate measures.

 

REFERENCES:

 

  1. Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet 2003; 361: 2226-34.
  2. Government of India (2006), Sample Registration System Bulletin, April 2006, Vol. 40, No. 1.
  3. Government of India (2005), Sample Registration System. Statistical Report No.2 of 2005.
  4. WHO ( 2005). The World Health Report 2005, Make every mother and child count.
  5. Newborn Health, Key to child survival. Child Health Division, Department of Family Welfare, Ministry of Health and Family Welfare, 2000.
  6. Barker DJ, Osmond C, Law CM. The intrauterine and early postnatal origins of cardiovascular disease and chronic bronchitis. J Epidemiol Community Health 1989; 43: 237-40.
  7. Student’s Handbook for Integrated Management of Neonatal and Childhood Illness. WHO, UNICEF and Ministry of Health and Family Welfare, Government of India, 2005.
  8. Kliegman RM, Behrman RE, Jenson HB: Nelson Textbook of Pediatrics 17th Elsevier 2004.
  9. Baraff LJ, Bass JW, Fleisher GR, Klein JO, et al. Practice guideline for the management of infants and children 0 to 36 months of age with fever without source. Pediatrics 1993; 92: 1-12.
  10. English M, Ngama M, Musumba C, et al. Causes and outcome of young infant admissions to a Kenyan district hospital. Arch Dis Child 2003; 88: 438-43.
  11. Ashworth A, Waterlow J. Infant mortality in developing countries. Arch Dis Child 1982 ; 57 : 882 – 4.
  12. Leach A, McArdle T, Banya W, et al. Neonatal mortality in a rural area of the Gambia. Ann Trop Pediatr 1999 ; 19 : 33 – 43.
  13. Oddie S J, Hammal D, Richmond S, Parker L. Early discharge and readmission to hospital in the first month of life in the northern region of the UK during 1998 : a case cohort study. Arch Dis Child 2005 ; 90 : 119 – 124.
  14. Patricia J. Martens, Shelley Derksen and Sumit Gupta. Predictors of hospital readmission of manitoba newborns within six weeks postbirth discharge : A population – based study. Pediatrics 2004; 114 (9) : 708 – 713.
  15. Escobar G J, Greene J D, et al. Rehospitalisation after birth hospitalisation : Patterns among infants of all gestations. Arch Dis Child 2005 ; 90 : 125 – 131.
  16. Gupta Piyush, Malhotra Saurabh, Singh Dharmendra K, et al. Length of postnatal stay in healthy newborns and re - hospitalization following their early discharge. Indian J Pediatr 2006 ; 73 (10) : 897 – 900.
  17. Duke T, Oa O, Mokela D, Oswyn G, Hwaihwanje I and Hawap J. The management of sick young infants at primary health centers in a rural developing country. Arch Dis Child 2005; 90: 200-5.
  18. English M, Ngama M, Mwalekwa L, Peshu N. Signs of illness in Kenyan infants aged less than 60 days. Bull WHO 2004 ; 82 (5) : 323 – 329.
  19. Bonadio WA, Smith DS, Sabnis S. The clinical characteristics and infectious outcomes of febrile infants aged 8 to 12 weeks. Clin Pediatr (Phila) : 1994 ; 33 (2) : 95 – 9.
  20. Hsiao AL, Chen L, Baker MD. Incidence and predictors of serious bacterial infections among 57 – to 180 - day – old infants. Pediatrics 2006; 117 (5) : 1695 – 701
  21. Gajdos, L. Foix L’ Helias, et al. Factors predicting serious bacterial infections in febrile infants less than three months old : multivariate analysis. Arch de pediatr 2005; 12 : 397 – 403.
  22. Kumar V, Singhi S. Predictors of serious bacterial infection in infants upto 8 weeks of age. Indian Pediatr 1994 ; 31 : 171 – 80.
  23. The WHO Young Infant Study Group. Bacterial etiology of serious infections in young infants in developing countries : results of a multicenter study. Pediatr Infect Dis J 1999; 18 : S17-22.
  24. S.M. Nawshad Uddin Ahmed, M.A.K. Azad Chowdhury, Mahbul Hoque and Gary L. Darmstadt. Clinical and bacteriological profile of neonatal septicemia in a tertiary level pediatric hospital in Bangladesh. Indian Pediatr 2002; 39:1034 –1039.
  25. Bachur R, Harper M. Predictive model for serious bacterial infections among infants younger than 3 months of age. Pediatrics 2001; 108 (8) : 311-16.
  26. Crain EF, Shelov SP. Febrile infants : predictors of bacteremia. J Pediatr 1982; 101 : 686 – 9.
  27. Gehlbach SH. Fever in children younger than three months of age. A pooled analysis. J Fam Pract 1988; 27 (3) : 305-12.
  28. Nathan Kuppermann, Edward A. Walton. Immature neutrophils in the blood smears of young febrile children. Arch Pediatr Adolesc Med 1999; 153: 261-266.
  29. Gennis PR, Skovron ML, Aranson ST, et al. The usefulness of peripheral venous blood in estimating acid-base status in acutely ill patients. Ann Emerg Med 1985; 14:845-49.
  30. Yildizdas D, Yapicioglu H, Yilmaz H L and Sertdemir Y. Correlation of simultaneously obtained capillary, venous and arterial blood gases of patients in a paediatric intensive care unit. Arch Dis Child 2004 ; 89 : 176 – 180.




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