The COPD Foundation's My COPD Action Plan should be filled out the first time as part of a discussion with your health care provider, and then used daily or as often as you can. Youll also find an interactive removable insert containing helpful forms, lists, and charts for making a disaster preparedness plan that is specific to your own needs. Sputum gram stain and culture (for COLD exacerbation), Imaging Chest radiography Emphysema: obvious bullae, paucity of parenchymal markings, or hyperlucency Hyperinflation: increased lung volumes, flattening of diaphragm Does not indicate chronicity of changes Chest CT Definitive test for establishing the diagnosis of emphysema, but not necessary to make the diagnosis, Diagnostic Procedures Pulmonary function tests/spirometry Chronically reduced ratio of FEV1 to forced vital capacity (FVC) In contrast to asthma, the reduced FEV1 in COLD seldom shows large responses (>30%) to inhaled bronchodilators, although improvements up to 15% are common. Its important for individuals with COPD to stay healthy and enjoy their favorite activities. Now customize the name of a clipboard to store your clips. Weve updated our privacy policy so that we are compliant with changing global privacy regulations and to provide you with insight into the limited ways in which we use your data. This booklet may also be beneficial to caregivers as well. the airway and out of the lungs permanent and what is, COPD - . 20-23 June 2023 Dublin, Ireland. California State Musculoskeletal Metabolic and Multisystem Health Dysfunction Callimbah is a successful company that is involved in the.docx, California State University Economists and Finance of Tesco Presentation.docx. Chronic obstructive pulmonary disease, also known as COPD, encompasses a group of diseases that cause problems with breathing. Author: Stephen Gundry is COPD nurse, Newcastle Hospitals NHS Foundation Trust. Chronic obstructive pulmonary disorders COPD. Barnett, M. (2008). Weve updated our privacy policy so that we are compliant with changing global privacy regulations and to provide you with insight into the limited ways in which we use your data. Considerations Problems other than COLD should be suspected when hypoxemia is difficult to correct with modest levels of supplemental oxygen. COPD. Pulmonary Disease Our beautiful, affordable PowerPoint templates are used and trusted by both small and large companies around the world. Presentations will focus on current and critical issues to provide oncology nurses with practical information that can be implemented in the practice setting. Ameritech College of Healthcare, Draper. In addition, we have included a multitude of resources that you can edit to convey your information, such as graphics, map, infographics, etc. Tap here to review the details. Click here to review the details. Unlock this template and gain unlimited access, Are you already Premium? Hallmark symptom - Dyspnea Chronic productive cough Minor hemoptysis pink puffer blue bloater. senario. aims & objectives. review. possible areas to cover. Tachypnea Accessory respiratory muscle use. By accepting, you agree to the updated privacy policy. Chronic Obstructive Each of the nine Guides for Better Living focuses on one important aspect of life with COPD. Activate your 30 day free trialto continue reading. Views: 837, By: DrDwayne Every COPD patient has an anticipatory care plan which is created by their GP . chronic bronchitis and Emphysema 28-7, Emphysema Pathophysiology Hyperinflation of alveoli Destruction of alveolar walls Destruction of alveolar capillary walls Narrowed airways Loss of lung elasticity, Emphysema Pathophysiology Two types: Centrilobular (central part of lobule) Most common Panlobular (destruction of whole lobule) Usually associated with AAT deficiency, Emphysema Pathophysiology Structural changes are: Hyperinflation of alveoli Destruction of alveolar capillary walls Narrowed, tortuous small airways Loss of lung elasticity, Emphysema Pathophysiology Small bronchioles become obstructed as a result of Mucus Smooth muscle spasm Inflammatory process Collapse of bronchiolar walls Recurrent infections production/stimulation of neutrophils and macrophages release proteolytic enzymes alveolar destruction inflammation, exudate, and edema, Emphysema Pathophysiology Elastin and collagen are destroyed Air goes into the lungs but is unable to come out on its own and remains in the lung Causes bronchioles to collapse, Emphysema Pathophysiology Trapped air hyperinflation and overdistention As more alveoli coalesce, blebs and bullae may develop Destruction of alveolar walls and capillaries reduced surface area for O2 diffusion Compensation is done by increasing respiratory rate to increase alveolar ventilation Hypoxemia usually develops late in disease, Emphysema Clinical Manifestations Dyspnea Progresses in severity Patient will first complain of dyspnea on exertion and progress to interfering with ADLs and rest, Emphysema Clinical Manifestations Minimal coughing with no to small amounts of sputum Overdistention of alveoli causes diaphragm to flatten and AP diameter to increase, Emphysema Clinical Manifestations Patient becomes chest breather, relying on accessory muscles Ribs become fixed in inspiratory position, Emphysema Clinical Manifestations Patient is underweight (despite adequate calorie intake), Chronic Bronchitis Pathophysiology Pathologic lung changes are: Hyperplasia of mucus-secreting glands in trachea and bronchi Increase in goblet cells Disappearance of cilia Chronic inflammatory changes and narrrowing of small airways Altered fxn of alveolar macrophages infections, Chronic Bronchitis Pathophysiology Chronic inflammation Primary pathologic mechanism causing changes Narrow airway lumen and reduced airflow d/t hyperplasia of mucus glands Inflammatory swelling Excess, thick mucus, Chronic Bronchitis Pathophysiology Greater resistance to airflow increases work of breathing Hypoxemia and hypercapnia develop more frequently in chronic bronchitis than emphysema, Chronic Bronchitis Pathophysiology Bronchioles are clogged with mucus and pose a physical barrier to ventilation Hypoxemia and hypercapnia d/t lack of ventilation and O2 diffusion Tendency to hypoventilate and retain CO2 Frequently patients require O2 both at rest and during exercise, Chronic Bronchitis Pathophysiology Cough is often ineffective to remove secretions because the person cannot breathe deeply enough to cause air flow distal to the secretions Bronchospasm frequently develops More common with history of smoking or asthma, Chronic Bronchitis Clinical Manifestations Earliest symptoms: Frequent, productive cough during winter Frequent respiratory infections, Chronic Bronchitis Clinical Manifestations Bronchospasm at end of paroxysms of coughing Cough Dyspnea on exertion History of smoking Normal weight or heavyset Ruddy (bluish-red) appearance d/t polycythemia (increased Hgb d/t chronic hypoxemia)) cyanosis, Chronic Bronchitis Clinical Manifestations Hypoxemia and hypercapnia Results from hypoventilation and airway resistance + problems with alveolar gas exchange, COPD Complications Pulmonary hypertension (pulmonary vessel constriction d/t alveolar hypoxia & acidosis) Cor pulmonale (Rt heart hypertrophy + RV failure) Pneumonia Acute Respiratory Failure, COPD Diagnostic Studies Chest x-rays early in the disease may not show abnormalities History and physical exam Pulmonary function studies reduced FEV1/FVC and residual volume and total lung capacity, COPD Diagnostic Studies ABGs PaO2 PaCO2 (especially in chronic bronchitis) pH (especially in chronic bronchitis) Bicarbonate level found in late stages COPD, COPD Collaborative Care Smoking cessation Most significant factor in slowing the progression of the disease, COPD Collaborative Care: Drug Therapy Bronchodilators as maintenance therapy -adrenergic agonists (e.g. Dr. Kaara Ray B. Calma is a full-time Lecturer in the School of Nursing and Midwifery at Deakin University Australia, and is a Registered Nurse with a PhD completed at the University of Wollongong Australia. *ctda0&?iOcdr0&O@(L%EUxmsy]r@y9`P COPD. This is one of the best free PPT templates for nursing. Youll like what you see! Chronic obstructive pulmonary disease by aminu arzet, Copd(chronic obstructive pulmonary disease), Chronic Obstructive Pulmonary Disease (COPD), Chronic obstructive pulmonary disease ppt, chronic obstructive pulmonary disease in equine. The DPP can also be found in the COPD Pocket Consultant Guide (PCG) app, available on the Apple App Store or Google Play. Total cost of COPD hospitalizations per year = $1.5 billion. 1.) In the Tips for Living Well with COPD flyer, you will learn about tools, techniques, and resources to help you on your journey with COPD. Paige Chavers DNP, ACNP-BC, MSPH: Views: 714, By: JenniferDwayne Click here to review the details. Activate your 30 day free trialto unlock unlimited reading. advance their professional expertise with presentations and earn more on top of their base rate.-High Reliability Organization (HRO): MedStar is an HRO. COPD: Conserving Your Energy. The inclusion criteria for . Temporary mechanical ventilation restored this patients gas exchange. working around certain kinds of chemicals, COPD - . Ventolin) MDI or nebulizer preferred Anticholinergics (e.g. Decreased quality of life. CrystalGraphics, Inc. 1999 S. Bascom Avenue Suite 700 Campbell, CA 95008 USA. Slide 1-. In addition, laminated versions are available through our online catalogue. Work with a versatile nursing presentation for PowerPoint. Nurse CHI Pulmonary and Sleep Medicine Jan 2022 - Present 1 year 3 months. dinner was great, coffee is brewing and you are all debating, COPD - . causes. Atrovent), COPD Collaborative Care: Oxygen Therapy O2 therapy Raises PO2 in inspired air Treats hypoxemia Titrate to lowest effective dose, COPD Collaborative Care: Oxygen Therapy Chronic O2 therapy at home Improved prognosis Improved neuropsychologic function Increased exercise tolerance Decreased hematocrit Reduced pulmonary hypertension, COPD Collaborative Care: Respiratory Therapy Breathing retraining Pursed-lip breathing Prolongs exhalation and prevents bronchiolar collapse and air trapping Diaphragmatic breathing Focuses on using diaphragm instead of accessory muscles to achieve maximum inhalation and slow respiratory rate See text re how to teach, COPD Collaborative Care: Respiratory Therapy Huff coughing (Table 28-21) Chest physiotherapy to bring secretions into larger, more central airways Postural drainage Percussion Vibration, Positions for Postural Drainage Fig. things are quiet. Activate your 30 day free trialto unlock unlimited reading. Change size. Clipping is a handy way to collect important slides you want to go back to later. Chronic Obstructive Pulmonary Disease - COPD. Remember to update it at least every six months. Designed to support NPs in primary care who play a crucial role in the management of patients with PAH, a rare, complex disease this tool explains the clinical presentations of PAH, provides an overview of treatment options and identifies when patients should be referred to pulmonary hypertension (PH) centers. Retrieved February 07, 2009 from Health Source: Nursing and Academic Edition Database. Views: 991, By: sherry -Continuous evaluation of classes and the course to . Chronic Obstructive Pulmonary Disease (COPD) is a condition of chronic dyspnea with expiratory airflow limitation that does not significantly fluctuate. all you wanted to know about copd but were afraid to ask. This flyer highlights the benefits and importance of quitting smoking at any age. Colorful theme enhanced with senior-man-as-a-patient backdrop and a lemonade . In the United States alone it affects about 16 million people. Comment We can be reasonably confident that patient 1 suffered hypoventilation due to the effect of the ingested drugs on the brain stem. Please Review ONE of the following videos and post for the class what you have learned. . Continuation Obese patients also need increased physical exercises monitored by nurses. Uploaded on Sep 27, 2014. 270 views. Systemic wasting Significant weight loss Bitemporal wasting Diffuse loss of subcutaneous adipose tissue Paradoxical respiration Inward movement of the rib cage with inspiration (Hoover's sign) in some patients "Pink puffers" are patients with predominant emphysemano cyanosis or edema, with decreased breath sounds. Aim: To synthesise qualitative research on pulmonary sequelae of COVID-19 and identify patient needs and experiences to develop nursing care strategies. "A key piece of learning for us was to create different presentations for different audiences so you can really target your . COPD (CHRONIC PULMONARY OBSTRUCTIVE DISEASE) by SUKHERA. Weve updated our privacy policy so that we are compliant with changing global privacy regulations and to provide you with insight into the limited ways in which we use your data. experiencing shortness of breath at rest or with minimal activity, such as walking from one room to another. Do not sell or share my personal information, 1. possible areas to cover. Instant access to millions of ebooks, audiobooks, magazines, podcasts and more. -Partner with the Center for Education, Simulation, and Innovation to develop patient scenarios that foster the development of critical thinking skills. COPD COMPLETE POWER POINT AS PER GOLD. chronic obstructive pulmonary disease in equine, COPD (Chronic obstructive Pulmonary Disease) PowerPoint Presentation -aslam, Chronic obstructive pulmonary disease (copd) power point, Nursing care plans, concept map bronhial asthma, Introduction & investigations to respiratory diseases, L'Docile - Respiratory diseases & nebulization Report, J. Parker Emphysema Presentation Powerpoint, COPD - Chronic Obstructive Pulmonary Disease |medico X| Pathology. Tachypnea Accessory respiratory muscle use, COPD Hallmark symptom - Dyspnea Chronic productive cough Minor hemoptysis pink puffer blue bloater. Clipping is a handy way to collect important slides you want to go back to later. COPD Foundation Guides for Better Living are comprehensive educational booklets for use by individuals with COPD and their families, pulmonary rehabilitation programs, COPD support groups, and health care facilities. NUR. Send us a message and help improve Slidesgo. Medications and treatments with things like respiratory exercise devices and inhalers can help you enjoy many good years with COPD. Physiotherapy management of chronic obstructive pulmonary disease ppt by Oluw COPD AND ICU MANAGEMENT : DR DEVAWRAT BUCHE, treatment Chronic Obstructive Pulmonary Disease. progressive obstruction over time. Blood gases drawn on room air revealed these values: patient 1- pH =7.18, PCO2 = 70mmHg, PO2=50mmHg, HCO3=24mEq/L; patient2- pH =7.31, PCO2=50mmHg, PO2=50mmHg, HCO3=25mEq/L, Comment The A-a gradient calculation for patient 1 is as follows: A-a DO2 = PAO2 PaO2 PAO2 = 150 (1.25x PCO2) PAO2 = 150 (1.25x 70) PAO2 = 62 A-a =62 50 A-a = 12. You can read more about the PCG tracks for patients and caregivers and for health care professionals. Often with COPD, patients you will see some combination of both presentations seen in chronic bronchitis and emphysema. PowerPlugs is a trademark of CrystalGraphics, Inc. We believe everyone should have access to free online first aid information which is up-to-date and accurate. Bandaged Teddy Bear - Nursing Templates Free. Appointments 216.444.6503. Slide 3-. She is a passionate nurse, educator and researcher, with research interests in undergraduate nursing education, nursing workforce, chronic illness experience, patient education, health . Reduction in forced expiratory flow rates Increases in residual volume Increases in ratio of residual volume to total lung capacity Increased total lung capacity (late in the disease) Diffusion capacity may be decreased in patients with emphysema. - PowerPoint PPT presentation. COPD - Physical Findings. Do not sell or share my personal information, 1. INTRODUCTION Click here to review the details. pulmonary diseases. COPD - . Pharmacotherapy of Chronic Obstructive Pulmonary Disease, CODP ( Chronic Obstructive Pulmonary Disease ). michele ritter, m.d. chronic obstructive pulmonary disease. Oxygen Therapy Basics is intended to support individuals who are new to (or curious about) supplemental oxygen therapy. Chronic obstructive pulmonary disease (COPD) is an umbrella term for two chronic lung conditions. Acute exacerbations of chronic obstructive pulmonary disease (COPD) are a risk factor for disease deterioration, 1 and patients with frequent exacerbations have increased mortality. Emphysema Number of Views: 87. Energy-conserving tips are presented. review oct. 16, 2014 cathy vakil. Lung cancer Clubbing of the digits is not a sign of COLD.In patients with COLD, development of lung cancer is the most likely explanation for newly developed clubbing. Asthma Reduced forced expiratory volume in 1 second (FEV1) in COLD seldom shows large responses (>30%) to inhaled bronchodilators, although improvements up to 15% are common. We've encountered a problem, please try again. This plan guides you when youre feeling well and when an exacerbation (flare-up) is starting. Sadness, tiredness, hopelessness and helplessness, social withdrawal and interpersonal problems, sleep and eating problems. Mr. Yahye Sheikh Abdulle Quieres ms informacin?Llame al 866.731.COPD (2673) y presione 9 para hablar en espaol con un paciente o cuidador. 2. INCIDENCE COPD is the 5th leading cause of death in . Background: If current trends in the management of COPD do not change, the predicted 4.5 million Australians diagnosed with COPD by 2050 will place significant burdens on already over-utilised frontline ED services. 28-16 Positions for Postural Drainage, COPD Collaborative Care Encourage patient to remain as active as possible, COPD Collaborative Care Surgical Therapy Lung volume reduction surgery Lung transplant, COPD Collaborative Care Nutritional therapy Full stomachs press on diaphragm causing dyspnea and discomfort Difficulty eating and breathing at the same time leads to inadequate amounts being eaten, COPD Collaborative Care Nutritional therapy To decrease dyspnea and conserve energy Rest at least 30 minutes prior to eating Use bronchodilator before meals Select foods that can be prepared in advance 5-6 small meals to avoid bloating Avoid foods that require a great deal of chewing Avoid exercises and treatments 1 hour before and after eating, COPD Collaborative Care Nutritional therapy Avoid gas-forming foods High-calorie, high-protein diet is recommended Supplements Avoid high carbohydrate diet to prevent increase in CO2 load, Nursing Management Nursing Diagnoses Ineffective airway clearance Impaired gas exchange Imbalanced nutrition: less than body requirements Disturbed sleep pattern Risk for infection, Nursing Management Nursing Implementation Health Promotion STOP SMOKING!!! Grace Parker (the patient's name has been changed) attends a nurse-led COPD clinic for routine reviews. Goal: Develop a PowerPoint presentation on CONGESTIVE HEART FAILURE (CHF) (Please explain implications on cardiovascular and respiratory system) The presentation must provide information about the incidence, prevalence, and pathophysiology of Congestive Heart Failure to the cellular level. Chronic Obstructive Pulmonary Disease . Operating Room Nurse/ Clinical Research Nurse . Because this study aimed to explore nurse observations of COPD patients in a naturalistic setting (during home visits), eligible patients were identified and included as a third party during the data collection process. -System-wide nurse referral bonus program - earn up to $6000 per referral. By: DrDwayne Clipping is a handy way to collect important slides you want to go back to later. pulmonary edema; North Carolina State University . 8% of all individuals 10% age >40 6 th leading cause of death worldwide, COPD - . It appears that you have an ad-blocker running. Widescreen (16:9) Presentation Templates. Hallmark symptom - Dyspnea Chronic productive cough Minor hemoptysis pink puffer blue bloater. We've updated our privacy policy. Both have ingested substantial amounts of barbiturates and diazepam. We've encountered a problem, please try again. COPD (chronic obstructive pulmonary disease) is a group of lung diseases that make it hard to breathe and get worse over time. Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable, and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities, usually caused by significant exposure to noxious particles or gases. A person with COPD may have chronic bronchitis . Presentation on Obesity Name Course Date Introduction Obesity is the excess of . The presentation must educate advanced practice nurses on assessment and . rada jones md 09/12/06. Free access to premium services like Tuneln, Mubi and more. COPD Description Characterized by presence of airflow obstruction Caused by emphysema or chronic bronchitis Generally progressive May be accompanied by airway hyperreactivity May be partially reversible. COPD - Physical Findings. Views: 670, By: DrDwayne If you have COPD, using less energy with daily tasks can help you have more energy to do more activities during the day. Enjoy access to millions of ebooks, audiobooks, magazines, and more from Scribd. Testing positive for COVID-19 can be scary and overwhelming, and people with COPD are at higher risk for severe symptoms. ={> 3 [Content_Types].xml ( r0;0\;6iCJr}.MxYv ]iLY'qDy. argy teaching resident, feb. 2007. View COPD Powerpoint.pptx from NUR 395 at Ameritech College of Healthcare, Draper. The Basics of COPD contains helpful information for individuals new to COPD. Free access to premium services like Tuneln, Mubi and more. Chronic Obstructive Pulmonary Disease Treatment Procedures in Hyderabad | Dr. Dr AGK Gokhale Cardiac Surgeon in Hyderabad, California State University Long Beach Sustainability and Food Paper.docx, California State Teaching Students with Hearing Losses Article Analysis.docx, California State University Thomas Kilmann Conflict Mode Questionnaire.docx. Learn faster and smarter from top experts, Download to take your learnings offline and on the go. -System-wide nurse referral bonus program - earn up to $6000 per referral. PowerPoint slide set summarizing GOLD's objectives, documents, and management recommendations from the 2022 update of the GOLD Report, with background information about COPD and the burden of this disease. diagnosis initial investigation, COPD - . Presentation having lung patient senior with oxygen . Muhammad Arslan Yasin Sukhera. Create stunning presentation online in just 3 steps. Skilled nursing in-services; Presentations regarding Medicare part D . Download Presentation. Many in this series of 12- to 20-page easy-to-read booklets feature interactive portions for patients and caregivers to discuss together. Distributions of forced expiratory volume in 1 s (FEV1)values in a generalpopulation sample, stratified by pack-years of smoking. Epidemiology >70% of COLD-related health care expenditures go to emergency department visits and hospital care (>$10 billion annually in the U.S.). COPD PowerPoint Presentation. These include: Average cost of hospital stay for ten days = $10,000. Msc Nursing 1st year It has a simple style, with a white background and light blue waves and . If you are preparing a presentation about it you can use this Slidesgo proposal. alison boland str respiratory medicine. or chronic bronchitis that was dr bruce davies www.bradfordvts.co.uk. This is an original nursing presentation for PowerPoint. Enjoy access to millions of ebooks, audiobooks, magazines, and more from Scribd. Chronic obstructive pulmonary disease, also known as COPD, encompasses a group of diseases that cause problems with breathing. By accepting, you agree to the updated privacy policy. Free access to premium services like Tuneln, Mubi and more. Now customize the name of a clipboard to store your clips. We've encountered a problem, please try again. The COPD Pocket Consultant Guide (PCG) app is built to support patients with COPD and their family members in self-management and to assist health care professionals in providing optimal care. Find a support group in your area to connect with others living with COPD and to learn from educational presentations and . mr. d has. COPD. o Presenting at 50 years of age o Strong family history o Predominant basilar disease o Minimal smoking history o Definitive diagnosis of 1AT deficiency requires PI type determination. Chronic Bronchitis Chronic lower airway inflammation Increased bronchial mucus production Productive cough Urban male smokers > 30 years old, Chronic Bronchitis Mucus, swelling interfere with ventilation Increased CO2, decreased 02 Cyanosis occurs early in disease Lung disease overworks right ventricle Right heart failure occurs RHF produces peripheral edema Blue Bloater, Emphysema Loss of elasticity in small airways Destruction of alveolar walls Urban male smokers > 40-50 years old, Emphysema Lungs lose elastic recoil Retain CO2, maintain near normal O2 Cyanosis occurs late in disease Barrel chest (increased AP diameter) Thin, wasted Prolonged exhalation through pursed lips Pink Puffer, COPD Management Oxygen Monitor carefully Some COPD patients may experience respiratory depression on high concentration oxygen Assist ventilations as needed, Diagnostic Approach Initial assessment History and physical examination (Signs & Symptoms) Pulmonary function testing to assess airflow obstruction Radiographic studies, Assessment of exacerbation History Fever Change in quantity and character of sputum ill contacts Associated symptoms Frequency and severity of prior exacerbations, Assessment of exacerbation Physical examination Tachycardia Tachypnea Chest examination Focal findings Air movement Symmetry Presence or absence of wheezing Paradoxical movement of abdominal wall Use of accessory muscles Perioral or peripheral cyanosis Ability to speak in complete sentences Mental status, Radiographic studies Chest radiography focal findings (pneumonia, atelectasis) Arterial blood gases Hypoxemia Hypercapnia Hospitalization recommended for: Respiratory acidosis and hypercarbia Significant hypoxemia Severe underlying disease Living situation not conducive to careful observation and delivery of prescribed treatment, ABG and oximetry Although not sensitive, they may demonstrate resting or exertional hypoxemia. Views: 1320. PowerPoint Presentation Last modified by: 3.) It is important to keep a list of your medications and immunizations handy. COPD- pulmonary hyperinflation- the diaphragms are at the level of the eleventh posterior ribs and appear flat. GOLD Teaching Slide Set. The SlideShare family just got bigger. Art of Assertive Commnunication, how to be visible in social media by Shreed UiPath Automation Cloud Robots - Best Practises session 2.pptx, How To Restore Tree From Ancestry To Family Tree Maker, INVERTING BUCK-BOOST DCDC CONVERTER DESIGN CHALLENGES. Icu management: DR DEVAWRAT BUCHE, treatment chronic obstructive Each of the eleventh posterior ribs and flat. Top experts, Download to take your learnings offline and on the brain stem all you wanted know! What you have learned to keep a list of your medications and treatments with things like respiratory exercise devices inhalers. 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