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Pat AjayiUniversity of the District of ColumbiaProfessor Jean-Baptiste, MSN/ED, MS, CCRN, CEN, RNPaper IIICapstone seminarIdentify the specific health care disparity Hypertension affects over 67 million people in the United States and has continuously remained one of the major chronic diseases contribution to the racially mortality gap between African Americans and their white counterparts (CDC 2008). African Americans have a higher prevalence with approximately 40% compared to 28% and poor medication adherence is a major contributing factor for poor blood pressure control (Chaplin et al. 2008). It is estimated that 1.4 million deaths is recorded overall each year from cardiovascular disease, and minorities suffer a great disproportion of this disease leading to an increased morbidity and mortality. Although there have been measurable advances made in the treatment of hypertension, yet the number of diagnosed hypertensive patients with controlled hypertension below pre-hypertensive levels of 140/90 still remains alarmingly low (Contrada et al. 2008). Arterial hypertension is an insidious chronic illness in the sense that throughout its course the client exhibits no symptoms for a very long period of time; it takes a while for the damages done by this disease to manifest in the form that will require treatment, hopefully, it is not too late for the individual. This is why the disease is frequently referred to as the “silent killer” as nothing is outwardly obvious in the physical sense, as the client remains asymptomatic, however, overtime, the client faces serious complications which include but not limited to cerebrovascular diseases and even death. Approximately twenty percent of the adult population is affected by this illness (Economou et al. 2010). The seriousness of the problem is shown nationally and globally, as uncontrolled hypertension leads to fatal complications. This paper will discuss the effects of non-compliance with anti-hypertensive medication, its impact on both the local and national arena and describe a clinical program proposal to address the disparity as well as provider rationale for the choice of the program. Establish the Significance of the Health Disparity in Local and National or Global Health: Among those with a diagnosis of hypertension, the World Health Organization has stated that low adherence to treatment is a key factor impeding good control and has called for research into adherence promoting interventions (Marshall et al. 2012). It is estimated that the rate of poor adherence or non-adherence to treatment range from 30-50% (CDC 2010). The causes of poor adherence are multi-facets which include complicated drug regimens, expensive drugs, older age, poor social support, cognitive deficits, and depression (Marshall et al. 2012). On the national level, cardiovascular disease is the leading cause of death among minorities in the United States. Hypertension alone accounts for sixty-seven million adults in this country; the burden of this prevalence higher in the minority population, as well as on a national scale, whereby higher proportion of patients from racial and ethnic minority groups suffer from hypertension. This is a significant number, it’s very alarming for such variance in proportion that prompted various studies, research, and for the government agencies to get involved to identify the causes, and seek out solutions to the problem.The prevalence of hypertension has been increasing in the past decade, particularly among African American whose prevalence rank among the highest in the world. One aspect of this problem is poor disease management, and low compliance to anti-hypertension medication, even though studies have indicated that adherence to medication regimen reduce blood pressure and greatly reduce morbidity and mortality (Contrada et al. 2008). One notable reason why the condition cannot be effectively treated is the low compliance to medication which is inherently a major problem in its management. In as much as hypertension is recognized to be one of the most significant but modifiable risk factors for not only cardiovascular disease, stroke, and end-stage kidney disease, it is also a big factor responsible for a total sum of cardiovascular death (Hedayati, et al. 2011). However, there are other contributing non-modifiable risk factors which in itself are irreversible, these include age, gender, and family history; and African American population fall in this category, other environmental factors which however can be reversed directly predisposes them to the risks of hypertension such as obesity, and diabetes. The real problem being confronted here it’s both economic and social as it relates to minority group. Because it has been reported that an estimated one in three Americans suffer from hypertension, as a result, it is safe to classify as an epidemic now needs more resources to address from it root causes. Even though significant improvements have been recorded for variety of choices for blood pressure management, it is still estimated that up to 50% of the clients with high blood pressure are still not adequately controlled (Ndumele, et al. 2010). This disparity exists primarily in the minority population, who have been deprived of basic economic and social services to alleviate them from poverty levels to a position where they would not be left behind by their white counterparts. On the local level as it relates to the District of Columbia, a national analysis conducted by Sperling (2012), identified Washington, D.C., as one of the nation's “Hypertension Hot Spots”, or is among the cities where hypertension and its attending risk factors, complications are extremely high. The identification of the “Hypertension Hot Spots” is part of a larger Takeda-sponsored hypertension awareness program called Commit to Control, which educates Americans about hypertension and also challenges patients to do all they can to get their blood pressure under control (Sperling, 2012). The study also found Washington, D.C., to rank 38th on the list of 50 U.S. metropolitan areas that have hypertension risk factors and complications (Sperling, 2012). Furthermore, in 2009, more than one-quarter of people in the District of Columbia had been informed they have high blood pressure, according to the Centers for Disease Control and Prevention. The large-scale Hot Spots analysis, which combined the findings of original research and existing, related research in the field of the study, analyzed data about numerous hypertension risk factors, including lack of exercise – Washington, D.C., ranked 16th highest nationwide – and mortality related to hypertension; Washington, D.C., ranked 20th highest nationwide (Sperling, 2012). The risks associated with untreated blood pressure cannot be under referenced; studies have more often concluded that if hypertension is not adequately controlled, it can lead to a higher risk of serious health consequences like heart attack and stroke. The brunt of such illness it’s not only to the individual, it also impacts the financial expense and costs of treatment and a huge burden to the patient and family member. The Hot Spots analysis emphasized the high prevalence of hypertension in the District and reiterates the significance of medication adherence in order to lower patients’ blood pressure, and reduce their risk for complications as well as decreasing the hypertension prevalence in the District. This can be achieved through patient-doctor relationship of close medication compliance monitoring, properly educating their patients on the risks of non-adherence, and ensuring that the patients are fully compliant (Sperling, 2012). There are many different types of disadvantaged neighborhoods in America, but poor urban minority neighborhoods seem to be especially unhealthy (Espstein, 2012). In analyzing some perception of the District, Espstein (2012) stated that it is largely believed that some poor neighborhoods have the highest mortality rates in the country, but is not mainly from crimes, gunshot or street drugs as one may believe, but the sad truth of the matter is, It is because of chronic diseases which are mainly diseases of adulthood, such as environmental, lifestyle, which are not caused by viruses, bacteria or other infections and that include stroke, diabetes, kidney disease, high blood pressure and other types of diseases.In a related study, Espstein (2012) concluded that the top five chronic disease affecting the District residents, hypertension make up 25%; even more troubling, over half of adult residents in the District qualify as overweight, and reports a correlation between obesity and hypertension. As a result of this social health problem, hypertension and associated chronic diseases cost the city over 2 billion dollars annually in medical costs. My target population includes 12 African American mail room employees and mail runners, who acknowledged being hypertensive, but non-compliant with their medication, who have also been identified through questionnaires are visual learners.Evidence Based Practices:African Americans have the highest overall mortality due to coronary heart disease of any racial/ethnic group in the United States (Bruschi et al. 2008). In comparison with whites, African American has a greater risk of stroke and a higher prevalence of hypertension. According to Bruschi et al. (2008) approximately 80% of patient with hypertension have additional cardiovascular risk factors, such as hyperlipidemia, which further increase their risk of cardiovascular event. And poor adherence to antihypertensive and lipid lowering therapies plays a significant role in this poor control.This problem is compounded by the low compliance to antihypertensive medication, even though studies have shown that the medication lowers blood pressure and reduces morbidity and mortality related to hypertension. Low adherence to medication is an inherent problem in the treatment of chronic, asymptomatic conditions and this is one reason why hypertension may not be treated effectively with drugs. Poor compliance to medication may also account for apparent resistance to therapy in more than one-third of the clientele (Bovet et al. 2010). Several studies have investigated the risk factors associated with low compliance with drug therapy and poor treatment results and has successfully demonstrated a number of factors could be attributed such as the educational level, male gender, young age, the initial drug choice, living alone, living in big cities, unemployment and increasing pill burden (Bovet et al. 2010). Conversely, other studies have suggested that people of higher socioeconomic status adhere better to antihypertensive treatment, which is not really surprising, since a silent condition such as hypertension is likely to require a good understanding of the long-term consequences to motivate compliance (Bovet et al. 2010). Further studies have suggested that multiple pill burdens have an adverse effect in adherence, therefore combination pill for example containing both antihypertensive and lipid-lowering agents or anti diuretic could improve the management of cardiovascular risk (Bruschi et al. 2008). As indeed recent results have suggested that patients receiving a single pill containing amlodipine/atorvastatin are 2 to 3 times more likely to be adherent than those receiving either co-administered amlodipine and atorvastatin or other two pill combinations of calcium channel blockers and statins (Bruschi et al. 2008). A variety of treatment options have been found to reduce or control blood pressure, including medications, improved diet such salt and fat restrictions, exercise, and weight loss (Aickin et al. 2011); however, in a study done by Contrada et al. (2008), examined illness beliefs, behaviors, and hypertension control among African American utilizing a commonsense model of self-regulation, found out that there was a mixed evidence of the effectiveness of other clinical treatment such as stress management/relaxation (Contrada et al. 2008). The commonsense model uses two cause-control models to view hypertension as primarily stress-related illness, therefore, if hypertension is caused by stress, it can be controlled by stress reduction, and secondly, if other hypertension involves biomedical factors and lifestyle behaviors such as heredity and poor diet, then it should be diet modification, medications, and exercise. It was further discovered that many African Americans tend to believe that hypertension is primarily a stress-related illness which has resulted to less medication adherence than others endorsing the biomedical/lifestyle model. The investigator found this reasoning very troubling, in the sense that, relying mainly on stress-management to reduce high blood pressure will escalate the rate of non- compliance to medications (Contrada et al. 2008). In contrast, since hypertension is largely an asymptomatic condition, Chaplin et al. (2008), found that patients had increased adherence if they believed that their medications affected symptoms, and newly diagnosed patients new to medication treatment are more likely to drop out when they misconstrue their disease to be acute, rather than chronic. Cheng (2010) explained that functional impotence is commonly associated with hypertension and is one of the most common side effects of many antihypertensive medications. It is a major cause of non-adherence to antihypertensive medication. Subsequently, medication to correct this and enhance sexual potency in men are available, however, physicians are very reluctant to prescribe such medication because its main side effect increases blood pressure to an undesirable range that if not carefully monitored can lead to a cardiovascular event (Cheng, 2010).Pharmacological treatment which includes beta-blockers have been said to be notorious for inducing sexual impotence, and the effect is dose-related (Cheng, 2010). Therefore black male patients tend to be non-compliant with taking the beta-blockers, although often they feel too embarrassed to report this side-effect to their physicians. The author stressed the importance of taking a complete sexual history from an African American patient, especially if he is on antihypertensive therapy. In a study conducted by Economou, et al. (2010), found ACE inhibitors to have another unpleasant side-effect such as cough, and thus promote bronchospasm and cough in susceptible individuals; as a result of this frequent and uncontrollable cough may constitutes an embarrassment, especially in public places such as churches and work place, hence this may lead to non-compliance to these ACE inhibitors drug therapy. And doctors are well aware of this and they usually warn the patients in advance before they start taking it, unfortunately, it has been reported that many of these patients never go back to their doctors, instead, they stop taking the medication altogether (Economou, et al. 2010). As indicated in a study published by Marshall et al. (2012), side effects were a widely reported which was another reason for self-adjusting or stopping drugs. The participants in the study described a range of adverse effects of treatment, many of which are listed in the medical literature, including leg swelling, urinary frequency, fatigue, and impotence. Lack of medication education was a lapse in adherence; patients on anti-diuretics were inappropriately taking the medication at night time; which explained the frequency in nocturnal urination. Perception of addiction played a key role in non-adherence as well as other longer term fears about the drugs, acting as sedatives overtime. A fear of addiction is not exclusive to hypertensive medication; however, qualitative studies have found that patients with other chronic medical problems reported identical views such as chronic pain. Conversely, several studies reported patients seeing treatment as essential, stating they would not contemplate missing even a single day of their medication. Nonetheless, the lack of symptoms makes compliance sometimes challenging; especially when the treatment is not curative or abolished any risk of cardiovascular disease. A systematic review by Marshall et al. in 2012 included 37 qualitative studies looking at drug taking habit of individuals in any medical condition including four hypertension studies were also reported in the review. The review found that patients saw drugs as undesirable and that many patients’ feared dependence and tolerance like they would in narcotics (Marshall et al. 2012). It was reported that even when patients would often test a new drug for a little time to check for adverse effects and whether symptoms were reduced, if they didn’t feel better to return to the state they were before they started the drug regimen, the tendency that non-compliance to the drug therapy will be extremely high.Description of the Assessment FormAn assessment form is the tool devised to elicit response from the participants; which will enable me to determine the level of compliance and provide an in-service to educate these clients in order to close the gaps in knowledge and compliance. The form is simple to understand, is at a fifth grade level of comprehension and the questions are directly related to the subject matter with closed ended answer of either “Yes or No” , an open ended questions or an opinionated form would have defeated the purpose. Salloway, (2012), expressed the benefits of closed –ended questionnaires as a survey tool emphasized that closed ended questions are more easily analyzed and suited for more specific questions when a direct answer is being elicited; also closed-ended questions is more likely to give the researcher similar meanings without trying to decipher someone else’s opinion. As opposed to open-ended questions whereby a narrative answer is required, I wanted the participants to give a simple yes or no response. I did not want them to express their opinion why they were not compliant with medication, the only valid answer I was seeking from this tool was an affirmation of whether they were being compliant or not. The rest personal reasons for not being compliant will be addressed at a different phase. There are six question components on the form, addressing six categories in an attempt to elicit an honest response to device a learning tool. The first question is checking for knowledge of their medication, because if you know what medicine is used to treat your condition, one is more apt to comply. The second component on the assessment list is check for tactile skills; that is actually being able to place the cuff around the arm and take a reading or have an awareness of stand-alone public places to go to check your blood pressure if you are unable to do it in the privacy of your own home. The third question is checking for compliance with doctors’ orders, this will give the research an insight of the patients’ comprehension of what the physician’s instructions are. The fourth question was knowledge based to see if there is an educational gap and where to concentrate the teaching efforts. The fifth component was to focus on the mind set and attitude of the client regarding blood pressure medication. It is important to know that taking blood pressure medication only when the pressure is high is not a trend that is encouraged, it may lead to dangerous consequences if this mind set and attitude remains unchanged. And lastly, the sixth component was validating the answer most cited by male for the reason of non-compliant. This is a factor that is significant to a lot of people, if there is any hindrance in sexual activities, it is more than likely that the hindrance will be eliminated which will be the blood pressure medication and not the activities they find pleasure in and enjoy.Studies have shown that based on an individual’s learning style, an appropriate tool will enhance effective learning. We have already established that my clientele are more visual learners. With that in mind, a pictorial brochure was developed depicting the disease process and affected organs in the hopes of leaving a lasting impression. The goal is for them to get to the point where they can take control of their own health by doing everything listed on the brochure; such as exercising, eating healthy and other lifestyle modifications.PATIENT ASSESSMENT FORMCOMPONENTSYESNODo you know the name of your BP medication? Do you know how to check your BP?Do you take your BP medication as prescribed? Do you know the side effects of your BP medication?I take my blood pressure medicine only when I feel my blood pressure is high. I don’t take my BP medicine because it affects my sex life.Rationale for choice of programUse education to break the myth associated with HTN drugs. Since it is ascertained that knowledge deficit is a contributing factor for non-compliance; therefore, education will play a pivotal role to influence learned behaviors. Education will increase the knowledge gained. The content of the program will be presented in a different light to enable the clients to relate and visualize the whole process and impress the significance of using medication to treat a chronic disease. Education on the disease will increase compliance; the focus is to practice what is taught to achieve the goal of being compliant. Education will enable patients to make healthy life choices. Lack of resources is another reason why the problem prevails, directing the client’s to where they can obtain these resources that will not cost them much is more likely to increase compliance.It will empower the patient to manage their health properly. Being educated a topic that can adversely affect someone’s life is a good motivation to want make less risky choices The anxiety related to the side effects of hypertensive medication will be put to rest. Knowledge is a powerful tool to ease anxiety, and increase compliance.Understanding the risks associated with non-medication compliance is very important because presenting vivid imageries of risking heart attack, stroke or kidney failure, will be an effective way of leaving a lasting impression. The goal of increasing medication compliance will be achieved. Short Term GoalsTo increase compliance to medication; in order to minimize any damages already done from years of being non-compliant; and to begin to understand the implications and complications they would eventually run into if they continue on the wrong path.To foster a greater understanding of the disease process is very vital to compliance, because self-discipline will be enhanced. To break the myth associated with medication will help establish a working relationship with their primary care practitioner to help them separate the truth from the myth.To educate on the risks associated with non-compliance will eliminate the ignorance associated with this disease, and initiate the process of educating themselves to avoid any challenging complications that is inevitable to occur if they maintain the status quo. To encourage healthy lifestyle modification to be optimal in the client’s daily regimen and to understand that simple changes in habit is not only beneficial to blood pressure control, but also to other aspects that may have been affected if lifestyle modification is not instituted. Long Term GoalsTo improve the general health and wellbeing of the targeted population. Adhering and committing to the stated objectives the prevalence statistically will be reduced, and one of the goals of Healthy People 2020 initiative to strive for a healthy nation will be achieved. To reduce the prevalence of the health disparity, if compliance is increased the morbidity and mortality rate will eventually be reduced among African Americans.To accept the disease as chronic and medication adherence prevents a cardiovascular event. Understanding that one pill will not cure this disease is very important, the continuous adherence to medication will maintain and the control blood pressure to levels that is healthy for the client. ObjectivesTo combat the issue of medication compliance among African America male who have the highest health disparity relating to anti-hypertensive medication.To analyze the client’s own perspective on the reasons why they are not compliantTo enumerate the gap in education and formulate a tool to address that gapTo utilize education and teaching to clarify uncertainty and promote adherence to blood pressure medications.To provide a pictorial brochure to enhance teaching and change behaviors.To implement best practices by incorporating evidence base practices to validate the need for complianceTo establish a trusting healthy relationship with primary care physician To identify risk factors to prevent a cardiovascular event thereby reducing the morbidity and mortality among this minority group. Measures to Evaluate OutcomesThe effectiveness of the in-service will be evaluated by the client’s response to a questionnaire check list. At the end of six weeks period following the initial in-service, the clients will be brought back, this time to evaluate the outcome of the teaching. According to Chaplin (2008), self-efficacy is an individual ability to use his or own judgment and confidence in his/her self to carry out a specific task to accomplish a desired outcome. The mechanism for evaluation is highly individualized, and largely dependent on the willingness and self-discipline of the client’s commitment to achieving a positive outcome. Secondly, taking responsibility aligns very well with Orem’s theoretical framework of self-care concept; which includes nursing concerns about the client’s response to illness and treatment, as well as about the client’s need for self-care (Chaplin 2008). Therefore, the questionnaire/checklist will be used to evaluate performance; and additional instructions will be provided for clients’ whose performance is not acceptable according to the rating sheet. This will be accomplished by having them demonstrate knowledge of the purpose and the effects of medications. They should be able to list the risk factors of hypertension, and the complication associated with non-compliance with medication. They will further verbalized the side effects of the medication and what intervention to prevent some of the known side effects. The clients would be able to check their blood pressure and know the values that are considered optimal. They should be able to describe some life style modification that they have inculcated into their daily activities.Another method to evaluate outcome is to have family member’s involvement and support the client. If the client is aware that he/she is not alone in this battle, the encouraging support and attitude of family members normally boost the self-esteem of the hypertensive client. Therefore, family members will be a viable source to evaluate successful outcomes because of the ease of forthright feedback from them. Furthermore, since this is a lifelong treatment, the efforts of the family member to assist the client in lifestyle modification and ensure compliance with medical treatment are very significant to attaining a therapeutic goal. Outcome evaluation may also be confirmed through the client’s primary care provider. Having the client establishing a good relationship with the client’s physician and nurse will foster compliance; even though the responsibility solely lies on the client to take his medication, a sincere interaction and collaboration between the client and health care givers must be available to provide open communication, counseling, education and training as they continue to navigate through the healthcare delivery system. Application of KSVME ModelAs already identified, lack of knowledge is a leading cause of non-compliant with anti-hypertension medication. Through education, knowledge is transferred to clients’ who have erroneously believed over the years that high blood pressure is due to stress and eliminating that causative factor will also eliminate the hypertension. Nurses should be able to apply knowledge of best practices through research to provide the needed education and training to the client. For example the knowledge gained from overwhelming literature on the use of anti-diuretics, should be included in the instructions on when to take the medication in order to prevent frequent urination at night. Nurses should be able to demonstrate tactile skills to the client to check their blood pressure as well as effectively communicate the steps and processes in applying the hand cuff when checking their blood pressure. This skill will build the client’s confidence in himself and eliminate the intimidation of using their personal blood pressure equipment to periodically check their pressure. It is important to note that, communicating the skill sets with the preceptor, may come as a second nature to the nurses or someone in the medical field, but for a mail room worker, it may sound like jargon to him. When hand-on skills are provided, the chances of the repeating the tasks again is increased. Nurses should also apply the values consistent with the ethical belief in a safe environment, while ensuring that integrity is not compromised. Being conscious of the client’s culture beliefs and values will enable the nurse to tailor the educational program to accommodate that choice in order to increase compliance to medication. For example, if there’s an ethical issue about taking medication after sundown, the nurse should provide education that will center around that belief to encourage compliance. Overtime the value of the newly acquired knowledge will resonate in more ways than one. As far as the meaning is concerned, nursing should be able to utilize concise language that is pertaining to the nursing practice as well as using simple language to illustrate the gains made through lifestyle modification for example weight loss and exercise will be viewed in a very positive light. The desired outcome will mean more to the client if nurses are able to put it in the context of simplified language that is unique to the client’s understanding. Understanding the reasons why it is important to change old habits, will continuously affirm the meaning of striving to achieve their goals. And finally, nurses should utilize the experience gained from school and also acquired from actively working in the clinical area to safely deliver care and provide education to the clients identified as more likely to be non-compliant with their hypertensive medication. Nursing experience will be replicated as nurses integrate nursing practice, knowledge of evidence based practices, communicating in language distinctive to the nursing practice, while upholding the shared values, and integrity of the profession. ReferencesAickin, M., Brantley, P., Elmer, J.P., Harsha, W., & Young, R.D. (2011). Physical activity, cardiorespiratory fitness, and their relationship to cardiovascular risk factors in African Americans with above-optimal blood pressure. Journal of Community Health, 30, (2), 107-117.Bovet, P., Burmier, M., Paccaud, F., & Waeber, B. (2010). Monitoring one-year compliance to antihypertension medication in the Seychelles. Bulletin of the World Health Organization, 80, (1), 33-39.Bruschi, P., Ferdinand, K., Flack, M. J., Jamieson, M., & Watson, K. (2008). Improved attainment of blood pressure and cholesterol goals using single-pill in African American: The Capable Trial. Mayo Clinic Proceedings, 83, (1), 35-45.Chaplin, W., Fernandez, S., Ogedegbe, G., & Schoenthaler, M. A. (2008). Revision and validation of the medication adherence self-efficacy scale in hypertensive African Americans. Journal of Behavioral Medicine, 31, 453-462.Cheng, T.O. (2010). Hypertensive disease in black patients. Oxford Journal of Medicine, 92, (8), 481.Contrada, J. E., Hekler, B. E., Lambert, J., Leventhal, E., & John, E. (2008). Commonsense illness beliefs, adherence behaviors, and hypertension control among African Americans. Journal of Behavioral Medicine, 31, 391-400.Economou, O., Fasoi, G., Kavga, A., Mandi, P., Nicolaou, M., & Saounatsou, M. (2011). The influence of the hypertensive patient’s education in compliance with their medication. Public Health Nursing, 18, (6), 436-442. Hedayati, S., Elsayed, E. F., & Reilly, R. F. (2011). Non-Pharmacological Aspects of Blood Pressure Management: What are the data? Kidney International Advance Online publication, 1-19.Marshall, J.I., McKevitt, C., & Wolfe, D.C. (2012). Lay perspectives on hypertension and drug adherence: Systematic Review of Qualitative Research. Journal of Behavioral Medicine, 10, 345-363. Ndumele, D. C., Shaykevich, S., Williams, D., & Hicks, L., S. (2010). Disparities in Adherence to Hypertensive Care in Urban Ambulatory Settings. Journal of Health Care for the Poor and Underserved, 21, 1-11.Epstein, H. (2012). Get healthy DC. Retrieved from . September 15, 2012.Salloway, L. (2012). The advantages of closed ended questions. Retrieved from November 25, 2012.Sperling, B. (2012). Washington, D.C., included in analysis of top hypertension hot spots in the United States. Retrieved from . Retrieved September 15, 2012hypertension. Retrieved September 15, 2012 ................
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