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NRP The Neonatal Resuscitation Program (NRP): An Initiative to Improve Care to Newborns at the Outset of Life.

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Presentation on theme: "NRP The Neonatal Resuscitation Program (NRP): An Initiative to Improve Care to Newborns at the Outset of Life."— Presentation transcript:


2 NRP The Neonatal Resuscitation Program (NRP): An Initiative to Improve Care to Newborns at the Outset of Life


4 NRP WHY DO WE NEED NRP ? 3 At least 10 % of all newborns require some assistance at birth i.e. the initial steps of resuscitation 3 And 1% require extensive resuscitation 3 There are 1 million deaths per year resulting from Birth Asphyxia (WHO, 1995) 3 A significant number will have respiratory problems and a large # will have seizures and later problems such as CP which means that one could possibly affect the outcomes of several million newborn infants every year

5 NRP NRP IN THE U.S.A. 1960s Mushrooming of neonatal and high risk OB care 1970s Regionalization of Perinatal Care Community Hospitals played pivotal role in neonatal resuscitation NIH funding of 5 educational grants to address neonatal resuscitation training American Academy of Pediatrics (AAP) forms group to address training

6 NRP NRP IN THE U.S.A. AAP and the American Heart Association led NRP development NRP faculty approach was tiered- National, Regional and Hospital Based A Standardized National Neonatal Resuscitation Program built on Consensus rolled out in the USA

7 NRP NRP in the U.S.A. Key Factors Sustaining It The most critical ingredient for the success of NRP….the goodwill and altruism of a broad and diverse group…this continues to sustain the program… Need for Continuing Education and Maintenance of Competency Linked to Accreditation of Institutions Standard of Care and Medico-Legal concerns

8 NRP NRP IN THE U.S.A. (contd) From 1987 until 2000, changes in NRP were largely the result of feedback from practitioners not necessarily based on evidence What is Evidence Based Medicine ? the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients

9 NRP Definition of Evidence Websters - something that furnishes proof Definition is subjective to interpretation Wide latitude as to what constitutes proof Can be reflected in guidelines and recommendations U.S. Preventive Services Task force developed Classification Schema for Quality of evidence

10 NRP Evidence Based Medicine in NRP Ten major questions were reviewed Extensive literature search on each topic Each article was assigned a level of evidence based on study design and methodology

11 NRP EBM - Steps in Evaluation Level of Evidence Level 1 = large randomized clinical trials or meta analyses of multiple randomized clinical trials Level 4 = Historic, non-randomized, cohort or case control studies Level 8 = Rational conjecture (common sense), common accepted practice before evidence based guidelines

12 NRP EBM - Next Step Critically evaluate the quality of each source in terms of research design and methods. Scale: Excellent to unsatisfactory Evaluate direction of the study results and the statistics Scale: Supportive, neutral, opposing proposal

13 NRP Final Step Determine the class of recommendation Class I - definitely recommended Class II - acceptable and useful Class II a - Acceptable and useful, very good evidence provides support Class II b - Acceptable and useful, fair to good evidence provides support Class III - Not acceptable, not useful, may be harmful

14 NRP NRP 2000 IN THE U.S.A. International Guidelines 2000 Conference on Cardiopulmonary Resuscitation and Emergency Cardiac Care formulated new evidence based recommendations for NRP Members included : AAP NRP Steering Committee, AHA and the Pediatric Working Group of the International Liaison Committee on Resuscitation (ILCOR)

15 NRP NRP 2000 GUIDELINES EVIDENCE BASED RECOMMENDATIONS Handling of infants with amniotic stained fluid stained Prevent heat loss and avoid hyperthermia Use of 100% oxygen only Potential use of laryngeal mask and exhaled CO 2 detectors Change in chest compression method and simplified rate response

16 NRP NRP 2000 GUIDELINES EVIDENCE BASED RECOMMENDATIONS Early administration of epinephrine Albumin no longer the fluid of choice; isotonic crystalloid solution is Potential for use of intraosseous route When resuscitation may not be initiated or may be discontinued in the delivery room


18 NRP Neonatal Resuscitation Program: Curriculum Dmytro Dobrianskyi, MD, PhD Keti Nemsadze, MD, PhD

19 NRP Program Components n Neonatal Resuscitation Program (NRP) developed in U.S. by the AHA and the AAP was used as a model in the NIS. n Main features of the Program 4 Implementation based on perinatal regions 4 Self-study textbook 4 Appropriateness for all professional levels 4 Adaptability for local practice n Formats of the NRP course 4 Self-study 4 Small group 4 1- or 2-day course

20 NRP Program Components n Educational resources of the original Program 4 Self-study textbook 4 Educational video 4 Approximately 300 slides 4 Skill stations (course training equipment) 4 Instructors Manual 4 NRP test package 4 Standardized final written evaluation and practical tests

21 NRP Program Components n Didactic components of the original Program 4 Student textbook provided prior to the course date 4 Provider Course consisting of 6 separate lessons, each covering a specific area of a neonatal resuscitation 4 Lectures and practical training at the skill stations 4 Instructor Course - to prepare those providers who would become teachers

22 NRP Program Content Assess babys response to birth Initial steps Establish effective ventilation Bag and mask Endotracheal intubation Provide chest compressions Administer medications Always needed by newborns Needed less frequently Rarely needed by newborns

23 NRP Program Components - NIS n All original educational NRP material was translated from English and distributed in the NIS (Russian, Ukrainian, Georgian). n NRP Training Centers were established. n Provider Training Course Standards are absolutely the same as the requirements in the U.S. The first courses in the NIS were co-taught with U.S. partners. n Program components and course formats used in the NIS were adapted to meet the needs of the Regions.

24 NRP Program Participants Anyone responsible for any part of a neonatal resuscitation is an appropriate candidate for a provider course. Historically, only physicians were considered participants in resuscitation Currently, neonatologists, obstetricians, midwives, nurses, anesthesiologists and pediatricians have been included in the provider courses.

25 NRP NRP Instructors n The key person in the NRP is an instructor, who is responsible not only for provider training but for implementation of the Program in every institution with delivery or newborn services. n To accomplish this the number of instructors need to be quite high to ensure the program will succeed in reaching all caregivers

26 NRP Organization of NRP Instructors in the USA

27 NRP Organization of NRP Instructors in the NIS

28 NRP NRP Instructors n To become an NRP instructor, a person must meet the following eligibility requirements: n Be a physician or nurse from critical care nursery setting 4 Have training and experience in the hospital care of newborns in a delivery room or critical care nursery setting. 4 Have educational or clinical responsibilities within a hospital or other appropriate medical facility (eg, medical school, nursing school). 4 Have a provider training or take an NRP Instructor Course that includes the provider component.

29 NRP NRP Instructors n It is important to emphasize that in the NIS settings, not all academicians can be instructors and conduct the NRP course because of its significant practical nature. n To achieve the objectives of the Program, practical clinicians must be widely involved into instructor activity.

30 NRP Instructor Training in the NIS n Instructors were trained as providers by US faculty, Provider Course (8 hours). n Instructor Course was used to provide physicians with knowledge of adult learning theory, principles of teaching and information on conducting a course (4 hours) n To enhance the level of expertise of instructors, a Train the Trainer (TOT) Course was developed. n Content of TOT includes basic physiological issues related to the care of high risk infants and is an additional resource to the original program.

31 NRP Importance of the Skill Stations The theoretical and practical knowledge of NRP and its implementation in maternity houses, significantly improves the quality of health care services contributing to desirable outcomes

32 NRP Importance of the Skill Stations Education on practical skills enables participants to establish newly acquired knowledge in everyday practice Working with small groups makes it possible to assess individuals, identify areas needing improvement and focus on these areas. Participants become familiar with equipment that is necessary for resuscitation and encounter simulated situations for practice. Improved skills, increases ones confidence in performing resuscitation correctly and efficiently

33 NRP Importance of the Skill Stations Participants observe each others mistakes as well as ways to problem solve Participants develop skills related to selection and functioning of appropriate equipment. Each skills station builds on the previous one, which gives participants the opportunity to master skills. This decreases the frequency of complications during resuscitation and enhance desirable outcomes. The performance check list gives the instructor an objective tool to evaluate participants knowledge, decision making and comfort with newly acquired skills

34 NRP The weak points of education in Former Soviet Union n Education was based only on theoretical issues. Practical skills were not taught. n No equipment and manikins were available for teaching practical skills n Medical staff were unfamiliar with equipment necessary newborn resuscitation and often could not use existing equipment despite the indications. n The first attempt at resuscitation usually was performed directly on a patient, therefore often delayed, performed incorrectly, resulting in frequent complications and resuscitation failure.

35 NRP Station I -Initial steps of resuscitation Importance 4 Important not only for a depressed infant but every newborn. 4 Making decisions about further steps of resuscitation happens here 4 This step requires only a few seconds, so mastering the sequence of the skills is very important. Common practice in Former Soviet Union Prevention of heat loss mostly was neglected Suctioning was not different in cases of clear or meconium stained amniotic fluid. Assessment of the infant was based on Apgar score assessed at I minute of life.

36 NRP Lesson 1:Initial steps of Resuscitation Heat loss preventionOpening of airways Assessment of the infant Place on warmer Dry the newborn Remove wet towel P osition the infant S uctioning mouth, then nose 3 if needed intubate and suctioning trachea Breathing Heart rate Color 3 if necessary provide tactile stimulation and give free flow oxygen

37 NRP

38 4 Supporting oxygenation, establishment of spontaneous breathing and timely prevention of hypoxia 3 getting acquainted with the equipment and how it works 4learning how to ventilate safely 4 identification of indications for chest compression Station 2 - Support Breathing Importance Common practicein Former Soviet Union 4 Harmful methods and prolonged tactile stimulation were used 4 Support breathing was based on medications 4 Ventilation with bag and mask was rare, mostly initiating breathing was conducted mouth-to-mouth breathing

39 NRP Station 2 - Support Breathing Selection of appropriate equipment and ensure it is functioning Performing ventilation 4Adequate rate 4Adequate pressure 4Assessment of adequate ventilation 4Assessment of HR 4Decision of next steps of resuscitation

40 NRP Station 3 - Support Circulation Importance 4Provision of artificial heart rate 4Restoring circulation Ensuring adequate oxygen supply Common Practice in Former Soviet Union 4 Chest compression was initiated primarily after cardiac arrest 4 Chest compressions were never combined with ventilation 4 Sometimes harmful methods of compression were used

41 NRP Technique position the infant firm support for the back, neck slightly extended 4 2 finger technique 4 thumb technique adequate location, depth and rate 4coordination of chest compression ventilation assessment of HR in sec. Station 3 - Support Circulation

42 NRP Station 4 - Endotracheal Intubation n Identification of indications 4 Ineffective bag and mask ventilation 4 prolonged ventilation 4 Tracheal suctioning 4 diaphragmatic hernia ImportanceCommon practice in Former Soviet Union 4 Intubation often was not limited to 20 sec 4 The indications were often ignored

43 NRP Technique 4 Position the infant 4 Insertion of laryngoscope and visualization of glottis 4 Insertion of ET tube 4 Checking the tube placement 4 Securing the tube Selection and preparation of the equipment 4Selection of the endotracheal tube size 4Selection and preparation of laryngoscope with appropriate size of blade 4Preparation of suctioning and ventilating equipment Station 4 - Endotracheal Intubation

44 NRP Tell me and Ill forgot Show me and I may not remember involve me, and I understand

45 NRP Quality Assessment of NRP Sudhakar G. Ezhuthachan, MD, DCH, FAAP

46 NRP Evaluation Strategies Evaluation of the course - maintaining course standards Evaluation of clinical application of knowledge Evaluation of patient outcomes

47 NRP Evaluation by Others U.S. NRP Steering Committee has just begun to discuss evaluation of the course Illinois, USA - Marked reduction in high risk infants with low apgars scores at 1 min. Of infants with low 1 min scores, more improved by 5 mins, in the group studied after the implementation of the NRP course

48 NRP Evaluation by Others Kerala, India - Use of a standardized curriculum like NRP reduced perinatal asphyxia after delivery Zhuhai, China - Neonatal Mortality (perinatally) was reduced by 3 times after NRP curriculum was introduced.

49 NRP IMPACT OF NRP EDUCATION at 10 centers in INDIA Pre training (3 m) Post training p value Total live births Resuscitation Bag/ Mask Ventilation 107 (2.1) 294 (4.1) <0.001 Intubations 113 (2.2) 153 (2.1) NS Apgar score <4 1 min 230 (4.5) 219 (3.0)< min 102 (2.0) 74 (1.0) <0.001 Outcome MAS97 (1.9) 157 (2.1) NS Respiratory distress 362 (7.1) 412 (5.7)<0.01 Seizures 107 (2.1) 49 (0.7) <0.001 Asphyxial Brain injury 102 (2.0) 49 (0.6) <0.001 Total deaths 159 (3.1) 176 (2.4) <0.05

50 NRP Early Attempts in Ukraine Data collected on every birth in maternity houses in western Ukraine Implementation sets were used as incentive Data sent monthly to the NRP Training Center Collection was tedious and not everyone participated

51 NRP Rater (per 1000) of CNS Abnormalities in 7 day-old newborns in 3 hospitals

52 NRP Evaluation of Courses First courses were co-taught with US faculty in most Centers Peer review process currently being developed and is to be discussed at next Steering Committee Meeting Key elements - instructor : student ratio, ensuring students have opportunity to be prepared, monitoring of exams, performance at skills stations

53 NRP Evaluation of Clinical Application Site visits conducted in Ukraine in May 1999, March 2001 Institutions evaluated - 3 in 1999, 6 in 2001 District as well as City sites Components evaluated - preparation of staff, equipment, performance of staff, knowledge base, clinical outcomes

54 NRP Preparation of Staff Staff Trained Neonatologists - 100% Obstetricians - 56% (in 2 places, 100%) Anesthesiologists - not active in training Nurses - 69% (2 places 100%, many who are not trained have been educated by MDs) Midwives - 50% (most deal only with mother while others resuscitate infant)

55 NRP Preparation of Staff Most had been trained in regional center, and one was an outreach course Student to instructor ratios appropriate All hospitals have a process to notify the resuscitation team of a delivery All hospitals transferred high risk mothers appropriately as soon as possible to the City

56 NRP Equipment The most crucial issue - one can educate a whole country, but without appropriate tools, clinical application is difficult Implementation sets distributed in 1997 were depleted Equipment is well taken care - guarded 8 of 9 had excellent Delivery Room set up Feedback from staff on equipment was obtained

57 NRP Performance Observation of deliveries and preparation for deliveries yielded positive application of principles Documentation in the medical record substantiated this finding Mock Codes may be helpful to aid in assessing and reinforcing knowledge

58 NRP Knowledge of Staff Pretests were used in Georgia -data pending 90% of institutions yielded good understanding of most principles Management of infants with meconium stained amniotic fluid needed reinforcement Thermal management issues uncovered in 2 institutions -water baths

59 NRP Clinical Outcomes Mortality is multifactorial and takes time to impact Morbidities related to temperature and low apgar scores show improvement

60 NRP Low Temperature and the Newborn A wet newborn loses heat very rapidly Hypothermia reduces the ability of the infant to respond to resuscitation efforts Hypothermia uses up energy (glucose) and oxygen, both needed by the brain. Effective temperature maintenance is critical for both survival and reducing morbidity

61 NRP THE EFFECTS OF LOW TEMPERATURE ON AN INFANT HYPOTHERMIA Cold Stress Acidosis Pulmonary Vessel Spasm Lack of Oxygen More Acid Production More Hypothermia Low Glucose Convulsions Death

62 NRP Numbers of Neonates Transferred with Hypothermia i.e. Temperature Lower than 35° C

63 NRP Reduction in % of Infants admitted to LOCH with Severe Perinatal Asphyxia

64 NRP Incidence of Severe Asphyxia in Infants admitted to LOCH

65 NRP Implementation Phases and Effectiveness of the Neonatal Resuscitation Program in Russia O. N. Belova

66 NRP The NRP Program has been operating as part of the Russian-American Partnership in Russia since years

67 NRP Order of Ministry of Health of the Russian Federation No. 372 Improvement of Primary and Resuscitation Care for Neonates in the Delivery Room became effective on 12/28/95. More than 5 years have passed

68 NRP The results of the implementation of the NRP protocol were summarized at the conference on Primary and Resuscitation Care for Neonates in the Delivery Room. Results of the Implementation of the Order of the Russian Ministry of Health No Problems. Outlook for Growth. Samara, October 2000

69 NRP Rating of the Results of the PNR Program by Respondents Excellent 30% 53% 17% Good Satisfactory

70 NRP Changes in Statistical Indicators as a Result of the Implementation of the NRP Protocol Find it difficult to respond- 25% See positive changes in statistical indicators- 62% Do not associate the positive changes with the effect of the order- 2% Do not see an association between indicators and negative changes- 2% Did not respond- 9%

71 NRP Positive Changes in Statistical Indicators Perinatal mortality- 22% Early neonatal mortality- 43% Infant mortality- 18% Death due to asphyxia, RDS, including low birth weight infants- 10% Neonatal mortality- 6%

72 NRP Changes in Indicators of Early Neonatal Mortality in the Russian Federation

73 Change in the type of primary resuscitation and state of neonates during in Maternity Hospital No. 27 in the city of Moscow (%)

74 NRP

75 Causes of Problems in Implementing the PNR Protocol Health care organizers regard level of knowledge of Order No. 372 as adequate- 6% Lack of understanding by local organization - 5% Disagreement with requirements of protocol - 2.5% Other - 2.5%

76 NRP The results of a questionnaire showed that only 63% of neonatologists have mastered neonatal resuscitation procedures The order of the Ministry of Health of the Russian Federation No. 372 Improvement of Primary and Resuscitation Care for Neonates in the Delivery Room became effective almost five years ago.

77 NRP Knowledge of neonatologists on the type of primary resuscitation care to be given to neonates based on pretest results - Passed - Failed

78 NRP In the opinion of 44% of the respondents, the primary reason for this is the absence of NRP training NRP resource training centers operate only in 5 regions within Russia

79 NRP Excerpt from the decree of the Board of the Ministry of Health of Russia of January 9, 2001 Infant Mortality and Ways to Reduce It : 9.6. To organize ongoing seminars for neonatologists on topics in primary neonatal resuscitation care

80 NRP Measures to Improve Neonatal Care Development/improvement of perinatal networks Creation of departments specializing in care of children who had problems at birth Increasing the role of mid-level medical personnel in providing NR

81 NRP Measures to Improve Neonatal Care Analysis of legal and ethical aspects of this issue Research (asphyxia, meconium aspiration, NR in children with ELBW, infection control during NR, oxygen therapy)

82 NRP A tree has grown from the seed planted by AIHA, USAID, and the Russian and American partners. And then...

83 NRP Neonatal Resuscitation Program in Ukraine: Results of Implementation Goyda N. M.D., Ph.D. Head, Medical Services Department Ministry of Health of Ukraine

84 NRP Key Indicators of Health of Children ( ) ( )

85 NRP Ratio of Stillbirth and Early Neonatal Mortality Causes

86 NRP Primary Disability Causes Ratio in Children 0-16

87 NRP Key Demographic Indicators

88 NRP List of Legal and Regulatory Documents, National, State and Target Programs in the Scope of Maternal and Child Health Care in Ukraine Long-term Program to improve status of women, family, Maternal and Child Care Complex Program to resolve disability problem National Program Children of Ukraine Additional activities to support implementation of the National Program Children of Ukraine up until CY 2005 National Program on Reproductive Health

89 NRP Key Objectives of the National Program Children of Ukraine Improvement of medical care to pregnant women and newborns Morbidity prevention and delivery of up-to- date medical care to children

90 NRP Decree of Ministry of Health January 5, 1996 Organization of medical service for newborns in Ukraine

91 NRP Three-Level System of Care of Newborns in Ukraine Level I - Resuscitation of newborns in a delivery room right after the delivery, which is primary resuscitation aimed at developing an adequate postnatal adaptation of a baby from the very first second of his life. Level II - Resuscitating in Newborn Departments at Maternity Hospitals and delivering intensive care. Level III - Delivering medical care to newborns in ICUs at Pediatric Regional and Multi-Specialty Pediatric City Hospitals.

92 NRP Implementing The Neonatal Resuscitation Program has made it possible for Ukraine to: Study the experience of U.S. leading neonatologists Teach Ukrainian Instructors Develop and equip Training Centers Start mass dissemination of neonatal resuscitation principles among medical staff Apply new medical techniques in neonatology Create a distinctively new system of health care delivery to newborns

93 NRP Standardized Approach to Training First Training Center was created through an AIHA partnership Replication of this model was used to open 5 additional centers Instructor training program was developed to help standardize the course format and prepare instructors Instructor training model has been used to train instructors from many countries.

94 NRP Standardized Approach to Training First courses were co-taught with U.S. faculty Now, Ukrainian faculty assist with co- teaching in other new centers Instructor:Student ratio maintained, 1:4-5 Certificates only issued if written exam and skill stations were independently completed

95 NRP Number of Specialists Trained in Training Centers

96 NRP Perinatal and Newborn Mortality in Ukraine ( )

97 NRP Neonatal Mortality in Regions where there are Training Centers

98 NRP The following issues remain unresolved: Legalizing the work of the centers Certification - national issues Standardization of program throughout Ukraine

99 NRP Suggestions with respect to further cooperation: Support the creation of 8-10 additional Training Centers due to the vast area of Ukraine Regular scientific forums on issues of primary newborn resuscitation Involvement of international experts in the development of national neonatology standards

100 Neonatal Resuscitation in Slovakia Peter Krcho MD,PhD NICU Perinatal Center Kosice Slovakia

101 NRP Situation before The newborns were not resuscitated by neonatal team Airway management Р not adequate and late The majority of cases did not receive adequate care... High neonatal mortality

102 NRP Our Priorities in 1992 Early detection of the problems after delivery in newborns Early resuscitation with bag and mask Better selection of the kind of follow up intervention that is necessary START with better CPR especially in perinatal centers CPR managed by neonatal physicians and nurses not by anesthesiologists IT WAS THE BEGINNING OF THE REGIONALIZATION PROCESS

103 NRP Present... Better collaboration between the units EBM interventions are now clear In most severe cases still intrauterine transport is the best...

104 NRP What are our priorities now Better intervention in all cases Intrauterine transport to the perinatal center Decrease of NM in the whole region especially in newborns under 1499g Delivery of high risk pregnancies in regional center,... under 999g

105 NRP Continue with... After 9 years of CPR projects we need to continue retraining Updating the training modality Use better education techniques- Real time video, www based education, better selection of the NICU team......skills, skills, skills...

106 NRP How did we make it... AAP/AHA training guidelines from 1992 Direct personal teaching Every neonatal physicians and nurses in contact with newborns resuscitation dolls, photodocumentation and direct participation in transport, or resuscitation in delivery room It has impacted networking, better confidence for the center


108 NRP Intrauterine transport to the Perinatal Center

109 Statistical Proof

110 NRP Still some severe problems... Can we provide the best skills over 24 hours? Can we build the best team in region? Can we maintain the same level with the same equipment? Can we follow the progress of the world...

111 Case Р ULBWN 540g

112 Sustainability / Dissemination / Teaching

113 NRP In Closing: Issues for the Future of NRP

114 NRP Sustainability Issues Ministry level support to legalizecenter activities and training Affiliation of centers with academic institutions Incorporation of NRP into CME to ensure standardization Development of a recertification process to ensure skills are maintained

115 NRP Sustainability Issues Quality monitoring of courses to ensure the certification process is legitimate Development of an outreach plan to ensure widespread dissemination Development of additional centers in large countries Obtaining basic resuscitation equipment for all institutions

116 NRP Sustainability Issues Technical support for centers to encourage continued networking and communication between hospitals, health departments and the Ministry Development of Perinatal Networks (regionalization) to support those infants who need continued care

117 NRP NRP TC - Start Up Costs Medical equipment for skills stations plus shipping$7, Office Equipment, furniture$ Educational materials$2, Training by US Trainers One 2 person trip$10, TOTAL$28,200.00

118 NRP NRP TC Maintenance Costs Telephone and connections $1, Equipment resupply, manuals, office supplies, printing$5, Outreach courses and quality assessment visits$5, Yearly total per center $12,040.00

119 NRP The Future of NRP in the Former Soviet Union NRP Steering Committee formed in 2000 Encourage collaboration between centers Establish standards for NRP Courses in these countries Learn from each other

120 NRP The Future of NRP in the Former Soviet Union Collectively address problems of sustainability Quality assessment plan implemented Implementation of new evidence based medicine guidelines, beginning with faculty training, Fall 2001

121 NRP

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