Dear Editor:
I would like to spot two obvious errors at the data extraction in the article by Kalichman et al on the systematic review of the prevalence of sexually transmitted coinfections in people living with HIV/AIDS. First, in Table 1 the study site of the Reference 31 by our study group, was located in Taiwan, instead of China. Second, it is clearly listed in the text of the Reference 31 that 79.7% of the participants had r...
Dear Editor:
I would like to spot two obvious errors at the data extraction in the article by Kalichman et al on the systematic review of the prevalence of sexually transmitted coinfections in people living with HIV/AIDS. First, in Table 1 the study site of the Reference 31 by our study group, was located in Taiwan, instead of China. Second, it is clearly listed in the text of the Reference 31 that 79.7% of the participants had received highly active antiretroviral therapy at enrollment, instead of "NR"in Table 1 - which probably means "not reported", though the author did not mention its meaning.
Madam,
We read with interest a recent article comparing the expectations and
experiences of STI care in general practice(1). The need for appropriate
sexual health services in primary care is clear especially when recent
data show the prevalence of HIV-1 to have reached 2 per 1000 in 37 primary
care trusts (PCTs) in England(2).
Patients interviewed in the study by Sutcliffe et al had initially
presented to general pract...
Madam,
We read with interest a recent article comparing the expectations and
experiences of STI care in general practice(1). The need for appropriate
sexual health services in primary care is clear especially when recent
data show the prevalence of HIV-1 to have reached 2 per 1000 in 37 primary
care trusts (PCTs) in England(2).
Patients interviewed in the study by Sutcliffe et al had initially
presented to general practice and were either recruited directly or had
been advised to attend a genito-urinary medicine (GUM) clinic and were
recruited there. Patients were recruited from areas of both high sexual
health need and differing ethic diversity, but were fundamentally a self-
selected group of patients who preferred to attend their GP over the GUM
clinic. It could be argued that they differ from GUM clinic attendees in
two unmentioned ways: Firstly, the median number of sexual partners in the
3 months prior to presentation in this study was 1 compared to >1 for
our clinic, which likely equates to less risk of having a sexually
transmitted infection (STI); secondly, that men who have sex with men
(MSM) were under-represented.
Data from the Gay Men's Sex Survey in 2003 revealed that while over 90%
were registered with a GP that only 32% from London and 29% from the South
West thought that staff at their surgery were aware of their sexuality(3).
Moreover, in a survey taken in 2009 from a dedicated gay men's clinic at
our centre only 21% of patients would attend their GP for sexual health
needs despite 83% having seen them in the preceding year (data
unpublished). This is all the more significant when MSM represented over
40% of gonorrhoea cases in London and the South West in 2009 (where sexual
orientation data were available) and 32% of HIV cases in the UK in 2010
(2,4).
In summary, whilst we strongly support enhanced links between primary and
secondary care for the provision of sexual health services, general
practice is not currently an acceptable option for all patients including
some of those with the highest need.
References
1. Sutcliffe LJ, Sadler KE, Low N, Cassell JA. Comparing expectations
and experiences of care for sexually transmitted infections in general
practice: a qualitative study. Sex Transm Infect. 2011;87:131-5.
2. Health Protection Agency UK. HIV in the United Kingdom: 2010
Report. Health Protection Report 2010 4(47). 2010.
http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1287145367237 (accessed
12th April 2011)
3. Sigma Research. On the move: findings from the United Kingdom Gay
Men's Sex Survey. 2003.
http://www.sigmaresearch.org.uk/files/local/All_England_2003.pdf (accessed
12th April 2011)
4. Health Protection Agency UK. Number of selected STI diagnoses made
at genitourinary medicine clinics in England, by age group and SHA of
residence. 2009.
http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1281953088000 (accessed
12th April 2011)
E-learning is the modern way of delivering the information required
for the induction programme at many NHS hospitals.
As a junior doctor who has undergone multiple inductions at different
hospital sites and into different specialties, I have found that the
training tracker was always a much better method of delivering induction
material. Having experienced lecture based inductions, which usually end
up with a l...
E-learning is the modern way of delivering the information required
for the induction programme at many NHS hospitals.
As a junior doctor who has undergone multiple inductions at different
hospital sites and into different specialties, I have found that the
training tracker was always a much better method of delivering induction
material. Having experienced lecture based inductions, which usually end
up with a lecture hall full of sleepy heads after 2 days, I wholeheartedly
support the e-learning option.
Not only is it still mandatory but it means that the true practical
induction of getting involved in the daily clinical work can begin much
sooner. It also has the advantage that it can be completed prior to the
start date, thereby facilitating service provision from that junior doctor
much sooner. The onus is on the trainee to identify areas of the induction
they may need further clarification on.
There still requires a system to check that all the junior doctors
have completed the required induction prior to starting and if not, the
trust should complete what is missing or encourage the trainee to complete
it.
Fox, Dunn and O'Shea stressed the importance of diagnosing primary
HIV infecting (PHI) to prevent onward transmission and help control the
HIV epidemic1. They evaluated the 4th generation HIV-1/2 Ag/Ag Determine
Combo assay (Alere) for its ability to detect p24 antigen as a marker of
PHI and have shown its poor sensitivity in detecting PHI and recommended
further evaluations of the assay. Many pati...
Fox, Dunn and O'Shea stressed the importance of diagnosing primary
HIV infecting (PHI) to prevent onward transmission and help control the
HIV epidemic1. They evaluated the 4th generation HIV-1/2 Ag/Ag Determine
Combo assay (Alere) for its ability to detect p24 antigen as a marker of
PHI and have shown its poor sensitivity in detecting PHI and recommended
further evaluations of the assay. Many patients self present to sexual
health clinics for a STI screen soon after an exposure which they perceive
as risky. Many clinics now offer rapid point of care (POCT) HIV testing
and although they are generally aware of the insensitivity of the 3rd
generation (antibody only) tests for PHI diagnosis, they could easily
assume that the new Determine Assay is equivalent in sensitivity to the
4th generation EIAs.
We performed a similar evaluation of the Determine assay at the HPA
Birmingham Public Health Laboratory and recently presented our findings at
the European Society for Clinical Virology winter meeting in London2.
Stored plasma samples were selected from patients who are at risk for HIV-
1 and who were screened between April 2008 and May 2010 using our routine
laboratory assays (Genscreen ULTRA HIV Ag-Ab Assay - Bio-Rad Laboratories
-, VIDAS HIV Duo Ultra HIV5, VIDAS HIV Duo Quick HIV6 p24 assay -
Biomerieux, Marcy l'Etoile, France). We selected 21 samples from patients
who either were diagnosed with acute HIV-1 seroconversion (14 samples) or
had a false positive reaction in one of our screening EIAs (7 samples).
All the samples were classified as either true seroconversion or false
positive by means of follow up samples. All samples were either p24 Ag
positive or equivocal. The definition of equivocal was a p24 Ag signal
value on the Vidas which was too low to be neutralised. For samples which
had enough serum a Vidas p24 Ag neutralising assay was performed of which
7/10 neutralised. All 7 false positive p24 Ag sera were correctly
identified by the Determine Combo test as negative. 5/14 of the p24 Ag
true positive sera (early seroconversion) were missed by the Determine
Combo test and tested negative for both p24 Ag and antibodies i e 64%
sensitivity compared to current laboratory EIA screening methods.
Even though there is a 64% improvement over a third generation (Ab
only) POCT, health care professionals should still be aware that the
Determine HIV-1/2 Ag/Ab Combo is not as sensitive as 4th generation EIAs
in diagnosing primary HIV-1 infections.
Husam Osman MBBCh, PhD, FRCPath
Consultant Virologist
HPA Birmingham, Public Health Laboratory
Heartlands Hospital
Birmingham
B9 5SS
Reference:
1. Fox J, Dunn H, O'Shea S. Low rate of p24 antigen detection using a
fourth generation point of care HIV Test. Sex Transm Infect 2010,Nov 17
2. Smit E, Atherton C, Osman H. Determine HIV-1/2 /Ab/Ag Combo lacks
sensitivity in detecting early HIV infections. European Society for
Clinical Virology Winter meeting, London, 13-15 Jan 2011.
It is impossible to judge the validity of this finding without data
on the confounding variables.
Given the Indian setting it seems likely that those who are
circumcised are Muslims whereas those who are not will be mostly Hindus.
As such the circumcised participants are subject to a different sexual
mores giving doubt to the conclusion.
Circumcision has long been advocated on the basis of simplistic...
It is impossible to judge the validity of this finding without data
on the confounding variables.
Given the Indian setting it seems likely that those who are
circumcised are Muslims whereas those who are not will be mostly Hindus.
As such the circumcised participants are subject to a different sexual
mores giving doubt to the conclusion.
Circumcision has long been advocated on the basis of simplistic
observational research. While this letter will no doubt give a warm
feeling to those who wish to promote circumcision, it provides no basis
for inflicting damaging surgery on those who have no disease and cannot
give consent.
Conflict of Interest:
Trustee of a charity representing the patients right to an autonomous decision about circumcision.
Hi, I am interested in the article which was published in 2008 called
Brief Encounters by Helen Ward and Emma Meader which concerns Chlamydia
and Toilet seats.
http://sti.bmj.com:80/cgi/content/full/84/2/107
Does this mean that it IS possible to catch an STI from a surface and that
they can survive on surfaces for up to 50 days and within that 50 remain
active enough to be caught? I am not just talking about c...
Hi, I am interested in the article which was published in 2008 called
Brief Encounters by Helen Ward and Emma Meader which concerns Chlamydia
and Toilet seats.
http://sti.bmj.com:80/cgi/content/full/84/2/107
Does this mean that it IS possible to catch an STI from a surface and that
they can survive on surfaces for up to 50 days and within that 50 remain
active enough to be caught? I am not just talking about chlamydia, but any
STI. The analysis of the results suggests that a hand touching a surface
which has been infected within the 50 day period can carry the infection
to another surface. It states that this proved positive in both cases,
when the original source was wet and even when it wasnt wet.
It seems especially from your article that you suggest that bacteria
from an STI can infect a surface and survive for 50 days and then be
transfered to a persons hand. Not only that but then it may transfer from
the persons hand to a 2nd clean surface.
Please could you clarify if this is the case.
Many Thanks
The letter by Philips et al1 about urological management of acute
epididymo-orchitis reflects the experience of all of us who pick up the
pieces after mis-management of epididymo-orchitis. However, before we can
criticise our Urology colleagues we really have to look at our guidelines
and see how useful they are? The BASHH Guideline for Management of
Epididymo-Orchitis2 is largely aimed at level 3 services that have ins...
The letter by Philips et al1 about urological management of acute
epididymo-orchitis reflects the experience of all of us who pick up the
pieces after mis-management of epididymo-orchitis. However, before we can
criticise our Urology colleagues we really have to look at our guidelines
and see how useful they are? The BASHH Guideline for Management of
Epididymo-Orchitis2 is largely aimed at level 3 services that have instant
access to microscopy, urinalysis and experienced sexual history taking.
However, the introduction states the guideline can also be applied to
other levels. Most epididymo-orchitis in this country is managed either in
A&E or urology with no access to microscopy, little knowledge of Chlamydia
and how to test for it, minimal use of urinalysis - either dipstick or
sending for culture. In that scenario, our guidelines are out of touch
with reality.
To expect an F2 in Urology on a Friday evening to distinguish whether
the epididymo-orchitis is of sexual or enteric origin is inappropriate.
Why make such a fuss over whether to use Doxycycline or Ciprofloxacin when
we know that Ofloxacin not only covers the organisms Ciprofloxacin would
cover but also covers Chlamydia? Sure, gonorrhoea would be a different
problem, but how many epididymo-orchitis cases are caused by gonorrhoea,
without a purulent urethral discharge which would have brought the patient
straight to a GUM clinic in the first place?
So, what we are really after here is getting urology to manage acute
epididymo-orchitis in a way that also covers Chlamydia. So, brief
history, out rule torsion, do 1st catch urine for dipstix, send off for
chlamydia and GC and other organisms. Start Ofloxacin 200mg bd for 2
weeks (generic cost, sterling 22.03) and refer to GUM at the earliest
opportunity. Before we criticise urology, therefore, we need to get our
own act together and produce a short, practical guideline for non GUM
clinic settings i.e. the real world where most of it is managed.
References
1. Phillips JT et al. Urological management of acute epididymo-orchitis
in sexually active young men: too great a public health risk. Sex Transm
Infect 2010;86:328.
2. http://www.bashh.org/guidelines management of epididymo-orchitis
2010. accessed Aug 2010.
We read the article by Fairley et al(1) with great interest. The
authors concluded that the decline in genital warts among women in the age
groups (<28 years) targeted for vaccination provides strong evidence
for the population-level effectiveness of the vaccine. They also report
that this conclusion was strengthened by the fact that no significant
decline in genital warts post vaccination has been noted among other ri...
We read the article by Fairley et al(1) with great interest. The
authors concluded that the decline in genital warts among women in the age
groups (<28 years) targeted for vaccination provides strong evidence
for the population-level effectiveness of the vaccine. They also report
that this conclusion was strengthened by the fact that no significant
decline in genital warts post vaccination has been noted among other risk
groups (e.g. men who have sex with men (MSM) who have not been targeted
for vaccination, and women >=28 years) other than men who have sex with
women (MSW). In addition to the authors' discussion about their study
limitations, we would like to highlight a few issues that suggest that the
data should be interpreted carefully.
Using trends from sexual health clinics to assess changes following
the introduction of a vaccination program may be misleading because this
type of data is amenable to different sources of biases especially that
the impact is measured only one year after the start of the vaccination
programme.
Although the authors mention that there have been "no changes in
clinic policy either relating to the selection of clients attending the
centre or clinical management and diagnosis", this does not guarantee that
the clientele has not changed. For example, using the data from table
1(1) to derive the denominator in each risk population, one realizes that
the annual number of clients attending the clinic started increasing after
2006, after a period mostly stable or declining, especially among MSM and
women age <28 years (~ 19% increase between 2006-2008). This shows that
a change in the number of attendances has occurred around the time that
the HPV vaccine was licensed in 2006.
In table 2(1), the authors interpret the fact that (in addition to
women age <28) the only statistically significant change, 5.0% decline
in the quarterly fraction of patients presenting with genital warts, was
among MSW as further evidence of the role of the vaccination program since
MSW may have benefited from the indirect impact of female vaccination.
However, since the number of MSM in the sample is three times less than
the number of MSW, it is also possible that the non-significant 5.9%
decline reported among MSM is simply due to a lack of statistical power.
If this was the case, this would beg the question as to why the fraction
of cases would have declined among MSM.
This information combined suggests that it is possible that the
client population presenting to the clinic may also have changed following
the licensing of the HPV vaccine, and especially after the beginning of
the vaccination programme. Indeed, the publicity around the licensing of
the new vaccine and the information and ad campaigns accompanying the
launch of the vaccination program may have changed the health seeking
behaviour of patients with HPV-related disease. The vaccination program
may have increased awareness and/or change the risk perception and anxiety
related to the disease. However, the direction of the potential bias is
difficult to predict as it may differentially affect those with or without
symptoms, vaccinated or not and could even be transient. Thus, it would
have been informative from Fairley et al's(1) to also present trends in
gonorrhoea prevalence, which is the usual marker of change in sexual
behaviour, rather than new HSV-2 cases(2), as well as trends in the number
of partners or other risk behaviour for each risk groups presented, which
seemed to have been available.
Nevertheless, these are encouraging preliminary results, which should
be interpreted carefully due to their limitations, especially after such a
short time following the start of the programme (one year). It is
important to continue the monitoring and evaluation of the programme over
many years and to confirm these types of results with additional data
source. Although, ideally, one would want data from representative random
samples of the general population, this will only be possible in rare
instances where cross-sectional studies of the general population are
repeatedly carried out at regular interval (e.g. NHANES(3)) as this is
difficult and expensive.
Instead it may be easier to collect more frequently data from
convenience samples of different risk populations, or to use population-
level consultation data (i.e. medical billings), which however are also
not immune from biases. In order to help the interpretation of time trends
of the primary disease outcomes of interest it would therefore be highly
desirable to complement this information with data on HPV vaccination
status and socio-demographics characteristics and even if challenging, if
at all feasible, basic sexual behaviour data.
Given the current attention given to the systematic evaluation of
intervention programme to help decision making, it is important to
carefully think about the formal evaluation of HPV vaccination programme.
References
(1) Fairley CK, Hocking JS, Gurrin LC, Chen MY, Donovan B, Bradshaw
BC. Rapid decline in presentations of genital warts after the
implementation of a national quadrivalent human papillomavirus vaccination
programme for young women. Sex Transm Infect 2009;85:499-502 Published
Online First: 16 October 2009
(2) Page KR, Moore RD, Wilgus B, et al. Neisseria gonorrhea and
Chlamydia trachomatis Among Human Immunodeficiency Virus-Infected Women
Sex Transm Dis. 2008, 35(10): 859-861.
(3) Dunne EF, Unger ER, Sternberg M et al Prevalence of HPV infection
among females in the United States JAMA 2007, 297(8): 813-819.
I thank Dr Alexander for her reply. However I question the
assumption that Chlamydia trachomatis is always a pathogen, wherever it is
found. Before we embark on what could be a costly programme of screening
for C. trachomatis in the throat and the rectum, do we not need some
evidence that the detection and treatment of asymptomatic infection in
those sites will be associated with clinical benefit in the patients and
th...
I thank Dr Alexander for her reply. However I question the
assumption that Chlamydia trachomatis is always a pathogen, wherever it is
found. Before we embark on what could be a costly programme of screening
for C. trachomatis in the throat and the rectum, do we not need some
evidence that the detection and treatment of asymptomatic infection in
those sites will be associated with clinical benefit in the patients and
their partners and a sustained elimination of the infection?
Richard Ma makes some excellent points in his editorial (1). I would like to 'correct' a
misperception but add to the current debate about HIV-testing and subsequent care within UK general practice.
Ma states that it was the use of highly active antiretroviral therapy (HAART) which precipitated the debates around shared care of patients with HIV infection. Unfortunately this is not true. For those old enough to
remember,...
Richard Ma makes some excellent points in his editorial (1). I would like to 'correct' a
misperception but add to the current debate about HIV-testing and subsequent care within UK general practice.
Ma states that it was the use of highly active antiretroviral therapy (HAART) which precipitated the debates around shared care of patients with HIV infection. Unfortunately this is not true. For those old enough to
remember, the serious debate began when patients with HIV and AIDS were denied local services and traditional primary care, particularly when entering the terminal stages of their illness (2). It was also apparent that patients living in one part of the country but receiving care in
London were having problems accessing general practitioner (GP)-type services (3). It is true that HAART seemed to focus the mind - it became fairly obvious that prescribing
could be one of the facets of care which could be examined in the "shared-care" process.
However, in the present context let's examine
some of the dynamics in shared care. Primary care is undoubtedly becoming more involved in the care of patients with HIV/AIDS though it has been argued that general practice could still do more (4), for example in
trying to uncover the unidentified 21000 people with HIV infection in the UK (5). Yet up to now the problem has been that patients have liked the highly successful hospital model, a model that has either implicity or in
some cases explicity "taken over" GP care.
In truth this gold standard model is not sustainable and this is the reason why general practice has to be more involved. The barriers to full primary care involvement have been outlined before (1,3,4) but
patient fears about disclosure, confidentiality and stigma are still present.
Things change in general practice as they do in Medicine; early in the UK it would necessarily take an hour to
'counsel'a patient about an HIV test, now we can do the test in the privacy of our consulting room and give the result to the patient 2 minutes later (we are about to
embark on point-of-care testing in our practice).
The real questions are these:
(a) How can we expect a more pressured primary (6) to take up the challenge of increasing testing when the priorities within general practice seem to increase all the time (6). Furthermore it is appropriate
to be mindful of the often complex needs of the various heterogenous groups which are affected by HIV infection (gay men, African men, women and children, drug-users)? As the recent research paper states
"further work is needed on the mechanisms
required to deliver increased HIV testing in primary
care"(7).
(b) Next and increasingly important especially if more cases of HIV infection are uncovered in GP, what is the optimal location for a systematic approach to HIV/AIDS - the chronic condition? In other words what system or systems will be responsible for regular patient monitoring of CD counts & viral loads, surveillance of cervical smears and perhaps immunisations as well as offering basic
prevention activities, for example smoking cessation advice in those already at higher risk of ischaemic heart disease?
References:
1. Ma, R. (Editorial) Time to improve HIV testing and recording of
HIV diagnosis in UK primary care: Sex Transm Infect 2009;85:486
doi:10.1136/sti.2009.038091
2. Smits,A., Mansfield,S., Singh,S. (1990). Facilitating care of
patients with HIV infection by hospital and primary care teams. British
Medical Journal 300, 241-243. ISSN: 0959-8146
3. Mansfield,S., Singh,S. (1993). Who should fill the care gap in HIV
disease? Lancet 342(8873), 726-728. ISSN: 0140-6736
4. Singh,S., Dunford,A., Carter,Y.H. (2001). Routine care of people
with HIV infection and AIDS: should interested general practitioners take
the lead? British Journal of General Practice 51(466), 399-403. ISSN: 0960
-1643
5. Health Protection Agency. HIV in the United Kingdom: 2009 Report.
2009, London, Health Protection Agency also available
athttp://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1227515298354 (accessed
7.1.2010)
6. Oakeshott, P; Aghaizu A; Prime, K; Hay P. Promoting long acting
reversible contraception & HIV-testing: more work for harassed GPs.
BJGP (2009) Vo 59 (569) 895-6
7. Evans HER, Mercer CH,Rait G et al. Trends in HIV testing and recording
of HIV status in the UK primary care setting: a retrospective cohort study
1995-2005. Sex Transm Infect
2009;85:520-6.
Madam, We read with interest a recent article comparing the expectations and experiences of STI care in general practice(1). The need for appropriate sexual health services in primary care is clear especially when recent data show the prevalence of HIV-1 to have reached 2 per 1000 in 37 primary care trusts (PCTs) in England(2). Patients interviewed in the study by Sutcliffe et al had initially presented to general pract...
E-learning is the modern way of delivering the information required for the induction programme at many NHS hospitals.
As a junior doctor who has undergone multiple inductions at different hospital sites and into different specialties, I have found that the training tracker was always a much better method of delivering induction material. Having experienced lecture based inductions, which usually end up with a l...
Dear Editor
Fox, Dunn and O'Shea stressed the importance of diagnosing primary HIV infecting (PHI) to prevent onward transmission and help control the HIV epidemic1. They evaluated the 4th generation HIV-1/2 Ag/Ag Determine Combo assay (Alere) for its ability to detect p24 antigen as a marker of PHI and have shown its poor sensitivity in detecting PHI and recommended further evaluations of the assay. Many pati...
It is impossible to judge the validity of this finding without data on the confounding variables.
Given the Indian setting it seems likely that those who are circumcised are Muslims whereas those who are not will be mostly Hindus. As such the circumcised participants are subject to a different sexual mores giving doubt to the conclusion.
Circumcision has long been advocated on the basis of simplistic...
Hi, I am interested in the article which was published in 2008 called Brief Encounters by Helen Ward and Emma Meader which concerns Chlamydia and Toilet seats.
http://sti.bmj.com:80/cgi/content/full/84/2/107
Does this mean that it IS possible to catch an STI from a surface and that they can survive on surfaces for up to 50 days and within that 50 remain active enough to be caught? I am not just talking about c...The letter by Philips et al1 about urological management of acute epididymo-orchitis reflects the experience of all of us who pick up the pieces after mis-management of epididymo-orchitis. However, before we can criticise our Urology colleagues we really have to look at our guidelines and see how useful they are? The BASHH Guideline for Management of Epididymo-Orchitis2 is largely aimed at level 3 services that have ins...
We read the article by Fairley et al(1) with great interest. The authors concluded that the decline in genital warts among women in the age groups (<28 years) targeted for vaccination provides strong evidence for the population-level effectiveness of the vaccine. They also report that this conclusion was strengthened by the fact that no significant decline in genital warts post vaccination has been noted among other ri...
I thank Dr Alexander for her reply. However I question the assumption that Chlamydia trachomatis is always a pathogen, wherever it is found. Before we embark on what could be a costly programme of screening for C. trachomatis in the throat and the rectum, do we not need some evidence that the detection and treatment of asymptomatic infection in those sites will be associated with clinical benefit in the patients and th...
Richard Ma makes some excellent points in his editorial (1). I would like to 'correct' a misperception but add to the current debate about HIV-testing and subsequent care within UK general practice. Ma states that it was the use of highly active antiretroviral therapy (HAART) which precipitated the debates around shared care of patients with HIV infection. Unfortunately this is not true. For those old enough to remember,...
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