•Complications can arise due to daytime sleepiness (sleep deprivation): such as cognitive dysfunction, depression and irritability. People with OSA are at an increased risk of motor vehicle accidents, most likely due to disordered reflexes and sleepiness. •Sleep apnoea can increase blood pressure, leading to an increased risk of stroke and myocardial infarction •Other CV complications include right-sided heart failure, atherosclerosis and arrhythmias •OSA may cause pulmonary hypertension or increase the severity of asthma
Mechanisms:
•Data suggests that apnoea causes the release of cytokines leading to inflammatory responses (cytokines released by ischaemic/hypoxemic cells, responses include raised C-reactive protein levels). C-reactive proteins characterise the progression of vascular injury and hence worsening vasculopathy. The release of inflammatory mediators also worsens asthma. •Hypoxic cells induce production of vascular endothelial growth factor and suppress antioxidative mechanisms (through the release of hypoxia inducible growth factor). This increases oxidative and carbonyl stress, which leads to endothelial dysfunction which can lead to hypertension and stimulate atherogenic processes. •Apnoea may possibly alter coagulative factors in the blood (Steiner, Altered blood rheology in obstructive sleep apnoea as a mediator of cardiovascular risk .Cardiology. 104 (2): 92-96, 2005): “CONCLUSIONS: Patients with OSA have elevated morning fibrinogen levels and a higher plasma viscosity, which correlate positively with indices of sleep apnoea severity. These changes in blood rheology are independent of cardiovascular risk factors, and therefore, might be specific mechanisms of OSA. This supports the pathophysiological concept that sleep apnoea is a cardiovascular risk factor.” Copyright (c) 2005 S. Karger AG, Basel.
Sources: http://www.patient.co.uk/showdoc/40001277/ http://www.sleep.scot.nhs.uk/osahs.html Arter JL. Chi DS. M G. Fitzgerald SM. Guha B. Krishnaswamy G., Obstructive sleep apnoea, inflammation, and cardiopulmonary disease. Frontiers in Bioscience. 9:2892-900, 2004 Sep 1. Jurkovicova, I. Celec, P. Mucska, I. Hodosy, J., On the origin of cardiovascular complications of sleep apnea syndrome by the means of molecular interactions. Bratislavske Lekarske Listy. 104(4-5):167-73, 2003. Happy studying, cya friday, Angela.
Signs and symptoms due to: Obstruction of airway - Loud snoring - Nocturnal chocking - Restless sleep Lack of sleep - Daytime sleepiness (Epworth Sleepiness Scale) - Morning headache - Trouble concentrating - Loss of energy Mood or behaviour changes - Irritability - Depression - Anxiety Hypertension - Increased heart rate - Ankle swelling Obstructive sleep apnoea is confirmed when the patient wakens from sleep 15 or more times in one hour. These awakenings can be so brief that the patient is unaware and only a sleep study can reveal them.
Disorder characterised by intermittent closure/collapse of the pharyngeal airway, causing apnoeic episodes - pauses in respiration lasting around 10 seconds - during sleep. These episodes are terminated by partial arousal.
References:
Oxford Handbook of Clinical Medicine, Sixth Edition.
http://www.patient.co.uk/showdoc/40025256/
(sorry guys, completely my bad - i'm chairing and i should have started the post earlier. hope everyone's caught up and relatively up to date...happy belated easter! happy almost over holidays!)
1)Uvulectomy: Laser assisted procedure consisting of incision of inferior rim of the soft palate and uvula. Tonsils are not removed. Can also have uvulopharyngoplasty, which involves shortening of the soft palate, amputating the uvula and removing redundant lateral and posterior pharyngeal wall mucosa from oral pharynx. But, improvements are only reported in less that 50% of patients (shows that there are multiple sites of upper airway obstruction).
2)Pillar System: Three woven inserts are placed into the soft-palate to reduce vibration that causes snoring and the ability of the soft palate to cause airway obstruction.
3)Nasal Reconstruction: Involves total or partial turbinectomies (opening up of nasal passage by removal of bone and soft tissue), submucous resection, cryotherapy, laser vaporization and radiofrequency ablation.
4)Adenotonsilectomy: Procedure where size of tonsils and adenoids (lymph nodes located behind throat) can be removed or reduced through methods preferred by the surgeon. Usually for paediatric patients.
5)Genioglossal advancement: Involves performing mandibular osteotomy with anterior repositioning of the genioglossus (extrinsic muscle of the tongue).
6)Palatial Surgery: Involves tonsillectomy and reorientation of the anterior and posterior tonsillar pillars, excision of the uvula and posterior rim of the soft-palate.
7)Thyrohyoid Suspension: Advancing Hyoid bone anterior and inferior to thyroid cartilage. Draws tongue forward making it less likely to fall to the back of the throat during sleep.
•Second line treatments
8) Maxillary-Mandibular Advancement: Procedure to widen the airway whilst maintaining occlusion. Also includes maxilla, mandible and chin surgery (Orthognathic surgery).
9)Tracheotomy: It bypasses the upper airway and is performed on patients with severe apnoea that is associated in life-threatening cardiac arrhythmias. Not commonly used today. Complications associated with tracheotomy include hemorrhage, recurrent infections, airway granulations, and tracheal or stomal stenosis.
Lifestyle Management of OSA -Weight loss Reduces obstructive episodes, improves blood gases and reduces daytime drowsiness
-Avoidance of alcohol and caffiene 4-6 hours prior to bedtime
-Quitting smoking
-Avoiding use of tranquilizers, sleeping pills & antihistamines These substances cause the soft tissues in the throat to sag and diminish the body's ability to inhale. Apnoea patients undergoing surgery should be sure that their doctors are aware of their sleeping disorder in considering sedatives, anesthetics, and medications taken to relieve pain due to surgery.
-Try sleeping on your side Mild sleep apnoea may be due to the effects of gravity, which cause the throat to narrow when a person lies on the back. (astronauts show a reduction in apneas and snoring in the weightlessness of space.) Positional sleep apnea affects people of all ages, including young children, however in overweight people, changing positions is less likely to help improve symptoms
- Use of nasal strips or sprays to reduce nasal obstruction (by opening the nostrils) Can help reduce mild sleep aponea (and snoring).
- It’s estimated that about 5% of Australians suffer from sleep apnoea. - In the over 30s age group, the disorder is about three times more common in men than women. -Most often in overweight middle-aged men. - People with significant sleep apnoea have an increased risk of motor vehicle accident and may have an increased risk of heart attack and stroke.
USA stats on OSA:
- Prevalance of Obstructive sleep apnea: 12 million Americans - Prevalance Rate: approx 1 in 22 people or 4.41% of US population
- Undiagnosed prevalence of Obstructive sleep apnea: as many as 10 million - Undiagnosed prevalence rate: approx 1 in 27 or 3.68% of US population
Sleep Studies A sleep study is an investigation carried out to try and determine the cause of sleep problems. They are most commonly done in a sleep lab.
The types of sleeps studies are: Polysomnogram • What it records: o Brain waves (Electroencephalogram - EEG) – used to tell whether patient is awake or asleep and what stage of sleep they are in. Records four forms of brain wave activity – alpha, beta, delta and theta waves. o Electrical activity of muscles (Electromyogram – EMG) Activity of muscles under the chin (submental muscle) - also helps to determine REM sleep and increased activity due to arousal upon resumption of respiratory effort Leg movements (tibialis muscle) – an arousal often detected after an episode of apnoea o Eye movement (Electrooculogram - EOG) – distinguishes REM sleep from other sleep o Airflow (Nasal airflow sensor) – records breath temperature, airflow including detection of apnoea and hypopnea events o Breathing effort (Chest/Abdomen belts) – elastic belts are placed around the chest and abdomen to measure depth of breathing and also detects apnoea and hypopnea events o Blood oxygen saturation (Pulse Oximeter) – drops progressively during an episode of apnoea o Snoring (Microphone) o Blood pressure o Heart rhythm (ECG) – to determine if any arrhythmias are present, slowing occurs during episodes of apnoea o Body position – supine, prone, side – in less sever cases of apnoea may only occur in supine position due to gravitational forces o Direct observation of the person during sleep (Video) • How it records o Electrodes placed on the chin, scalp, outer edge of the eyelids and legs o Each device hooks up to a polysomnogram which charts the measurements throughout the night • If severe sleep apnoea is discovered or suspect during the earlier stage of the study, the second half of the night may be used for CPAP (Continuous positive airway pressure) titration to determine the necessary pressure to alleviate apnoea. Alternatively if sleep apnoea is discovered during the study, the patient may be advised to return for a second night CPAP titration.
Multiple Sleep Latency Test (MSLT) • Test of how long it takes to fall asleep. Usually repeated 4 or 5 times in one day. Abnormally short time before you fall asleep is seen is sleep deprivation, severe sleep apnoea and narcolepsy. • Normal values are between 10-15 minutes • Apnoea patients can be consistently less than 5 minutes
Stages of sleep: • Relaxed wakefulness (usually with eyes closed) – alpha waves detected • Non-rapid eye movement (NREM) o Stage 1 – First and lightest stage involves transition from wakefulness to the onset of sleep, occupies about 10% or less of total sleep time, but can be as much as 30-50% in patients with sleep apnoea –slight slowing of EEG o Stage 2 – Next lightest stage, harder to arouse, occupies about 50% of normal sleep time – theta waves – bursts of sinusoidal waves called sleep spindles and high-voltage waves called K complexes o Stage 3 – Brain waves are slower in frequency than stage previous stages, ‘deeper ‘ sleep – high amplitude delta waves o Stage 4 – Even deeper than stage 3, often goes back and forth with stage 3 and together they occupy about 10% of sleep time – high amplitude delta waves - usually very little of this slow wave sleep (stages 3 and 4) in patients with sleep apnoea • Rapid eye movement (REM) o Paralysis of skeletal muscles except eye and diaphragm o Most dreaming occurs in this stage but can also occur in NREM sleep o EEG appears similar to NREM stage 1 • REM and NREM sleep alternate approximately every 90 mins. In normal sleep there are about 4-5 cycle per night.
References Principles of Neural Science 4th Edition – Kandel, Schwartz and Jessell http://www.med.monash.edu.au/medicine/alfred/research/sleep/glossary.html http://www.lakesidepress.com/pulmonary/Sleep/OSA.htm http://www.talkaboutsleep.com/sleep-basics/viewasleepstudy.htm http://en.wikipedia.org/wiki/Polysomnogram
In the case of sleep apnoea, two levels of treatment can be provided depending on the severity of the sleep apnoea. Lifestyle issues are addressed first, but if these prove ineffective, or OSA is severe, alternative management treatments must be used. These treatments include the use of a CPAP (Continuous positive airways pressure) machine or oral application devices.
CPAP is basically a ventilation device that blows air into the patients lungs like a backwards vacuum cleaner. In doing so, the machine keeps the airways open – by blowing them out like a balloon. This treatment is highly effective in maintaining a positive airways pressure and preventing periods of apnoea or hypopnea.
The CPAP machine is calibrated based on the patients needs as determined by sleep studies test which must be performed in a sleep laboratory first. The machine itself is fairly portable and simple, consisting of a box, tube and mouthpiece. To increase patient compliance, several features may be available with specific models of the CPAP machine including a humidifier (so that air is not dry), heated air, reduced pressure during expiration (so that outbreath is easier), a muffler (to quiet machine).
Oral application devices are mouthpieces which are fitted by a dentist, and work by keeping the mandible and tongue properly aligned, to prevent obstruction of airway. The devices can be used on their own or in conjunction with CPAP. There are two main kinds of oral application devices – • Tongue retaining devices (stops tongue from obstructing airway) • Mandibular retaining devices (moves the lower jaw forward – bringing tongue and other throat tissues with it, hence opening airway)
If lifestyle changes and CPAP/oral application treatments prove to be ineffective or intolerable to the patient, surgical management is indicated.
9 comments:
COMPLICATIONS OF OBSTRUCTIVE SLEEP APNOEA (OSA)
•Complications can arise due to daytime sleepiness (sleep deprivation): such as cognitive dysfunction, depression and irritability. People with OSA are at an increased risk of motor vehicle accidents, most likely due to disordered reflexes and sleepiness.
•Sleep apnoea can increase blood pressure, leading to an increased risk of stroke and myocardial infarction
•Other CV complications include right-sided heart failure, atherosclerosis and arrhythmias
•OSA may cause pulmonary hypertension or increase the severity of asthma
Mechanisms:
•Data suggests that apnoea causes the release of cytokines leading to inflammatory responses (cytokines released by ischaemic/hypoxemic cells, responses include raised C-reactive protein levels). C-reactive proteins characterise the progression of vascular injury and hence worsening vasculopathy. The release of inflammatory mediators also worsens asthma.
•Hypoxic cells induce production of vascular endothelial growth factor and suppress antioxidative mechanisms (through the release of hypoxia inducible growth factor). This increases oxidative and carbonyl stress, which leads to endothelial dysfunction which can lead to hypertension and stimulate atherogenic processes.
•Apnoea may possibly alter coagulative factors in the blood (Steiner, Altered blood rheology in obstructive sleep apnoea as a mediator of cardiovascular risk .Cardiology. 104 (2): 92-96, 2005):
“CONCLUSIONS: Patients with OSA have elevated morning fibrinogen levels and a higher plasma viscosity, which correlate positively with indices of sleep apnoea severity. These changes in blood rheology are independent of cardiovascular risk factors, and therefore, might be specific mechanisms of OSA. This supports the pathophysiological concept that sleep apnoea is a cardiovascular risk factor.” Copyright (c) 2005 S. Karger AG, Basel.
Sources:
http://www.patient.co.uk/showdoc/40001277/
http://www.sleep.scot.nhs.uk/osahs.html
Arter JL. Chi DS. M G. Fitzgerald SM. Guha B. Krishnaswamy G., Obstructive sleep apnoea, inflammation, and cardiopulmonary disease. Frontiers in Bioscience. 9:2892-900, 2004 Sep 1.
Jurkovicova, I. Celec, P. Mucska, I. Hodosy, J., On the origin of cardiovascular complications of sleep apnea syndrome by the means of molecular interactions. Bratislavske Lekarske Listy. 104(4-5):167-73, 2003.
Happy studying, cya friday, Angela.
Signs and Symptoms of Obstructive Sleep Apnoea
Signs and symptoms due to:
Obstruction of airway
- Loud snoring
- Nocturnal chocking
- Restless sleep
Lack of sleep
- Daytime sleepiness (Epworth Sleepiness Scale)
- Morning headache
- Trouble concentrating
- Loss of energy
Mood or behaviour changes
- Irritability
- Depression
- Anxiety
Hypertension
- Increased heart rate
- Ankle swelling
Obstructive sleep apnoea is confirmed when the patient wakens from sleep 15 or more times in one hour. These awakenings can be so brief that the patient is unaware and only a sleep study can reveal them.
References
Kumar and Clark
SLEEP APNOEA - DEFINITION
Disorder characterised by intermittent closure/collapse of the pharyngeal airway, causing apnoeic episodes - pauses in respiration lasting around 10 seconds - during sleep.
These episodes are terminated by partial arousal.
References:
Oxford Handbook of Clinical Medicine, Sixth Edition.
http://www.patient.co.uk/showdoc/40025256/
(sorry guys, completely my bad - i'm chairing and i should have started the post earlier. hope everyone's caught up and relatively up to date...happy belated easter! happy almost over holidays!)
Correction Procedures:
•Conservative procedures are
attempted first
1)Uvulectomy: Laser assisted procedure consisting of incision of inferior rim of the soft palate and uvula. Tonsils are not removed. Can also have uvulopharyngoplasty, which involves shortening of the soft palate, amputating the uvula and removing redundant lateral and posterior pharyngeal wall mucosa from oral pharynx. But, improvements are only reported in less that 50% of patients (shows that there are multiple sites of upper airway obstruction).
2)Pillar System: Three woven inserts are placed into the soft-palate to reduce vibration that causes snoring and the ability of the soft palate to cause airway obstruction.
3)Nasal Reconstruction: Involves total or partial turbinectomies (opening up of nasal passage by removal of bone and soft tissue), submucous resection, cryotherapy, laser vaporization and radiofrequency ablation.
4)Adenotonsilectomy: Procedure where size of tonsils and adenoids (lymph nodes located behind throat) can be removed or reduced through methods preferred by the surgeon. Usually for paediatric patients.
5)Genioglossal advancement: Involves performing mandibular osteotomy with anterior repositioning of the genioglossus (extrinsic muscle of the tongue).
6)Palatial Surgery: Involves tonsillectomy and reorientation of the anterior and posterior tonsillar pillars, excision of the uvula and posterior rim of the soft-palate.
7)Thyrohyoid Suspension: Advancing Hyoid bone anterior and inferior to thyroid cartilage. Draws tongue forward making it less likely to fall to the back of the throat during sleep.
•Second line treatments
8) Maxillary-Mandibular Advancement: Procedure to widen the airway whilst maintaining occlusion. Also includes maxilla, mandible and chin surgery (Orthognathic surgery).
9)Tracheotomy: It bypasses the upper airway and is performed on patients with severe apnoea that is associated in life-threatening cardiac arrhythmias. Not commonly used today. Complications associated with tracheotomy include hemorrhage, recurrent infections, airway granulations, and tracheal or stomal stenosis.
Bibliography:
1)http://www.cda-adc.ca/jcda/vol-67/issue-11/652.html
2)http://www.emedicine.com/ent/topic370.htm
*tut tut Rasha..great start to your career as chair...coulnt even set the blog up on time...* haha
Lifestyle Management of OSA
-Weight loss
Reduces obstructive episodes, improves blood gases and
reduces daytime drowsiness
-Avoidance of alcohol and caffiene 4-6 hours prior to bedtime
-Quitting smoking
-Avoiding use of tranquilizers, sleeping pills & antihistamines
These substances cause the soft tissues in the throat to sag and diminish the body's ability to inhale. Apnoea patients undergoing surgery should be sure that their doctors are aware of their sleeping disorder in considering sedatives, anesthetics, and medications taken to relieve pain due to surgery.
-Try sleeping on your side
Mild sleep apnoea may be due to the effects of gravity, which cause the throat to narrow when a person lies on the back. (astronauts show a reduction in apneas and snoring in the weightlessness of space.) Positional sleep apnea affects people of all ages, including young children, however in overweight people, changing positions is less likely to help improve symptoms
- Use of nasal strips or sprays to reduce nasal obstruction (by opening the nostrils)
Can help reduce mild sleep aponea
(and snoring).
http://www.health.gov.bc.ca/gpac/pdf/apnea.pdf
http://www.umm.edu/patiented/articles/what_lifestyle_measures_medications_used_sleep_apnea_000065_7.htm
PREVALANCE OF SLEEP APNOEA
- It’s estimated that about 5% of Australians suffer from sleep apnoea.
- In the over 30s age group, the disorder is about three times more common in men than women.
-Most often in overweight middle-aged men.
- People with significant sleep apnoea have an increased risk of motor vehicle accident and may have an increased risk of heart attack and stroke.
USA stats on OSA:
- Prevalance of Obstructive sleep apnea: 12 million Americans
- Prevalance Rate: approx 1 in 22 people or 4.41% of US population
- Undiagnosed prevalence of Obstructive sleep apnea: as many as 10 million
- Undiagnosed prevalence rate: approx 1 in 27 or 3.68% of US population
oops, I did it again!
References:
http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Sleep_apnoea
http://www.wrongdiagnosis.com/o/obstructive_sleep_apnea/stats.htm
Sleep Studies
A sleep study is an investigation carried out to try and determine the cause of sleep problems. They are most commonly done in a sleep lab.
The types of sleeps studies are:
Polysomnogram
• What it records:
o Brain waves (Electroencephalogram - EEG) – used to tell whether patient is awake or asleep and what stage of sleep they are in. Records four forms of brain wave activity – alpha, beta, delta and theta waves.
o Electrical activity of muscles (Electromyogram – EMG)
Activity of muscles under the chin (submental muscle) - also helps to determine REM sleep and increased activity due to arousal upon resumption of respiratory effort
Leg movements (tibialis muscle) – an arousal often detected after an episode of apnoea
o Eye movement (Electrooculogram - EOG) – distinguishes REM sleep from other sleep
o Airflow (Nasal airflow sensor) – records breath temperature, airflow including detection of apnoea and hypopnea events
o Breathing effort (Chest/Abdomen belts) – elastic belts are placed around the chest and abdomen to measure depth of breathing and also detects apnoea and hypopnea events
o Blood oxygen saturation (Pulse Oximeter) – drops progressively during an episode of apnoea
o Snoring (Microphone)
o Blood pressure
o Heart rhythm (ECG) – to determine if any arrhythmias are present, slowing occurs during episodes of apnoea
o Body position – supine, prone, side – in less sever cases of apnoea may only occur in supine position due to gravitational forces
o Direct observation of the person during sleep (Video)
• How it records
o Electrodes placed on the chin, scalp, outer edge of the eyelids and legs
o Each device hooks up to a polysomnogram which charts the measurements throughout the night
• If severe sleep apnoea is discovered or suspect during the earlier stage of the study, the second half of the night may be used for CPAP (Continuous positive airway pressure) titration to determine the necessary pressure to alleviate apnoea. Alternatively if sleep apnoea is discovered during the study, the patient may be advised to return for a second night CPAP titration.
Multiple Sleep Latency Test (MSLT)
• Test of how long it takes to fall asleep. Usually repeated 4 or 5 times in one day. Abnormally short time before you fall asleep is seen is sleep deprivation, severe sleep apnoea and narcolepsy.
• Normal values are between 10-15 minutes
• Apnoea patients can be consistently less than 5 minutes
Stages of sleep:
• Relaxed wakefulness (usually with eyes closed) – alpha waves detected
• Non-rapid eye movement (NREM)
o Stage 1 – First and lightest stage involves transition from wakefulness to the onset of sleep, occupies about 10% or less of total sleep time, but can be as much as 30-50% in patients with sleep apnoea –slight slowing of EEG
o Stage 2 – Next lightest stage, harder to arouse, occupies about 50% of normal sleep time – theta waves – bursts of sinusoidal waves called sleep spindles and high-voltage waves called K complexes
o Stage 3 – Brain waves are slower in frequency than stage previous stages, ‘deeper ‘ sleep – high amplitude delta waves
o Stage 4 – Even deeper than stage 3, often goes back and forth with stage 3 and together they occupy about 10% of sleep time – high amplitude delta waves - usually very little of this slow wave sleep (stages 3 and 4) in patients with sleep apnoea
• Rapid eye movement (REM)
o Paralysis of skeletal muscles except eye and diaphragm
o Most dreaming occurs in this stage but can also occur in NREM sleep
o EEG appears similar to NREM stage 1
• REM and NREM sleep alternate approximately every 90 mins. In normal sleep there are about 4-5 cycle per night.
References
Principles of Neural Science 4th Edition – Kandel, Schwartz and Jessell
http://www.med.monash.edu.au/medicine/alfred/research/sleep/glossary.html
http://www.lakesidepress.com/pulmonary/Sleep/OSA.htm
http://www.talkaboutsleep.com/sleep-basics/viewasleepstudy.htm
http://en.wikipedia.org/wiki/Polysomnogram
Medical Management of OSA
In the case of sleep apnoea, two levels of treatment can be provided depending on the severity of the sleep apnoea. Lifestyle issues are addressed first, but if these prove ineffective, or OSA is severe, alternative management treatments must be used. These treatments include the use of a CPAP (Continuous positive airways pressure) machine or oral application devices.
CPAP is basically a ventilation device that blows air into the patients lungs like a backwards vacuum cleaner. In doing so, the machine keeps the airways open – by blowing them out like a balloon. This treatment is highly effective in maintaining a positive airways pressure and preventing periods of apnoea or hypopnea.
The CPAP machine is calibrated based on the patients needs as determined by sleep studies test which must be performed in a sleep laboratory first. The machine itself is fairly portable and simple, consisting of a box, tube and mouthpiece. To increase patient compliance, several features may be available with specific models of the CPAP machine including a humidifier (so that air is not dry), heated air, reduced pressure during expiration (so that outbreath is easier), a muffler (to quiet machine).
Oral application devices are mouthpieces which are fitted by a dentist, and work by keeping the mandible and tongue properly aligned, to prevent obstruction of airway. The devices can be used on their own or in conjunction with CPAP. There are two main kinds of oral application devices –
• Tongue retaining devices (stops tongue from obstructing airway)
• Mandibular retaining devices (moves the lower jaw forward – bringing tongue and other throat tissues with it, hence opening airway)
If lifestyle changes and CPAP/oral application treatments prove to be ineffective or intolerable to the patient, surgical management is indicated.
References:
http://sleepdentist.ca/Appliances/index.html
http://www.health.gov.bc.ca/gpac/pdf/apnea.pdf
http://en.wikipedia.org/wiki/Bilevel_positive_airway_pressure
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