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  1. Reidpath DD, Jahan NK, Mohan D, Allotey P
    Glob Health Action, 2016;9:31691.
    PMID: 27511810 DOI: 10.3402/gha.v9.31691
    BACKGROUND: The term HbA1c (glycated haemoglobin) is commonly used in relation to diabetes mellitus. The measure gives an indication of the average blood sugar levels over a period of weeks or months prior to testing. For most low- and middle-income countries HbA1c measurement in community surveillance is prohibitively expensive. A question arises about the possibility of using a single blood glucose measure for estimating HbA1c and therefore identifying poor glycaemic control in resource-poor settings.

    DESIGN: Using data from the 2011-2012 US National Health and Nutrition Examination Surveys, we examined the relationship between HbA1c and a single fasting measure of blood glucose in a non-clinical population of people with known diabetes (n=333). A linear equation for estimating HbA1c from blood glucose was developed. Appropriate blood glucose cut-off values were set for poor glycaemic control (HbA1c≥69.4 mmol/mol).

    RESULTS: The HbA1c and blood glucose measures were well correlated (r=0.7). Three blood glucose cut-off values were considered for classifying poor glycaemic control: 8.0, 8.9, and 11.4 mmol/L. A blood glucose of 11.4 had a specificity of 1, but poor sensitivity (0.37); 8.9 had high specificity (0.94) and moderate sensitivity (0.7); 8.0 was associated with good specificity (0.81) and sensitivity (0.75).

    CONCLUSIONS: Where HbA1c measurement is too expensive for community surveillance, a single blood glucose measure may be a reasonable alternative. Generalising the specific results from these US data to low resource settings may not be appropriate, but the general approach is worthy of further investigation.

  2. Cheong WL, Mohan D, Warren N, Reidpath DD
    J Palliat Med, 2019 May;22(5):545-552.
    PMID: 30570416 DOI: 10.1089/jpm.2018.0447
    Background:
    The state of palliative care research is closely linked to the development of palliative care services in a country or region.
    Objective:
    To systematically review the current state of palliative care research in the Asia Pacific region and analyze its relationship with the performance of each country in the region on the Economist Intelligence Unit's 2015 Quality of Death Index.
    Design:
    Systematic review and bibliographic analysis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocol 2015 (PRISMA-P).
    Data Sources:
    The PubMed/MEDLINE, EMBASE, SCOPUS, CINAHL, and PsychiNFO databases were searched on February 4, 2018.
    Results:
    One thousand six hundred sixty-seven articles were reviewed. Eighteen out of 32 countries in the region published research. Around 74.15% (1236) of the articles were produced by high-income countries. Research output (articles per 1 m population) was closely linked to country performance on the Economist Intelligence Unit's 2015 Quality of Death Index (adjusted R2= 0.85). Palliative care research in the region is overwhelmingly focused on cancer (80.13% of articles reviewed). The most common themes of research were "palliative care service (24.45%)" and "clinical" (15.38%).
    Conclusions:
    Palliative care research in the region is growing but remains largely centered on the high-income countries, with many low- and middle-income countries having little published research output. Much work is required to drive research in these countries to generate the evidence required for the development of palliative care services. The emphasis on cancer in research also indicates that the needs of patients suffering from noncancer-related diseases may be neglected.
  3. Cheong WL, Mohan D, Warren N, Reidpath DD
    Front Neurol, 2018;9:432.
    PMID: 29937752 DOI: 10.3389/fneur.2018.00432
    Background: Multiple sclerosis is thought to be relatively uncommon in the Asia Pacific region with prevalence estimated between 0 and 20 per 100,000. There is reason to doubt these estimates due to the lack of data from many countries and the growing evidence of variability in prevalence across small geographic areas. This study was conducted to systematically review the population prevalence, incidence, mortality and disability progression estimates of MS within the Asia Pacific region. Methods: The systematic review was conducted on articles from 1985 till 31st July 2017 within the PubMed/MEDLINE, EMBASE, SCOPUS, and The Cochrane Library databases. The review included articles that were population-based studies conducted on patients with MS in the Asia Pacific region that reported either incidence, prevalence, mortality, or disease progression. Hospital-based studies and non-research articles were excluded to ensure that only information representative of the population was included for analysis. Data appraisal and extraction was done by independent reviewers. This review was registered with PROSPERO (ID: CRD42017082760). Findings: Of the 2,757 articles found, 16 studies were included. Information on 6 (18.75%) of 32 Asia Pacific countries was found, with data representing 8% of the total population. Prevalence estimates were available for 6 countries while estimates for incidence (3 countries), mortality (4 countries), and disease progression (2 countries) were limited. Interpretation: The lack of epidemiological data available in the Asia Pacific region creates a blind spot in the surveillance of MS which obscures the true burden of MS, causing patients to struggle to receive the resources and funding that they need.
  4. Mohan D, Iype T, Varghese S, Usha A, Mohan M
    BMJ Open, 2019 03 20;9(3):e025473.
    PMID: 30898818 DOI: 10.1136/bmjopen-2018-025473
    OBJECTIVES: To assess the prevalence and factors associated with mild cognitive impairment (MCI) among older adults in an urban area of South India.

    SETTING: The study was conducted in the capital city of Thiruvananthapuram in the South Indian state of Kerala.

    PARTICIPANTS: The study participants were community-dwelling individuals aged 60 years and above.

    PRIMARY OUTCOME MEASURE: MCI was the primary outcome measure and was defined using the criteria by European Alzheimer's Disease Consortium. Cognitive assessment was done using the Malayalam version of Addenbrooke's Cognitive Examination tool. Data were also collected on sociodemographic variables, self-reported comorbidities like hypertension and diabetes, lifestyle factors, depression, anxiety and activities of daily living.

    RESULTS: The prevalence of MCI was found to be 26.06% (95% CI of 22.12 to 30.43). History of imbalance on walking (adjusted OR 2.75; 95 % CI of 1.46 to 5.17), presence of depression (adjusted OR 2.17, 95 % CI of 1.21 to 3.89), anxiety (adjusted OR 2.22; 95 % CI of 1.21 to 4.05) and alcohol use (adjusted OR 1.99; 95 % CI of 1.02 to 3.86) were positively associated with MCI while leisure activities at home (adjusted OR 0.33; 95 % CI of 0.11 to 0.95) were negatively associated.

    CONCLUSION: The prevalence of MCI is high in Kerala. It is important that the health system and the government take up urgent measures to tackle this emerging public health issue.

  5. Cheong WL, Mohan D, Warren N, Reidpath DD
    Mult Scler Relat Disord, 2019 Oct;35:86-91.
    PMID: 31357123 DOI: 10.1016/j.msard.2019.07.009
    BACKGROUND: Despite the global consensus on the importance of palliative care for patients with multiple sclerosis (MS), many patients in developing countries do not receive palliative care. Improving access to palliative care for MS requires a contextual understanding of how palliative care is perceived by patients and health professionals, the existing care pathways, and barriers to the provision of palliative care.

    OBJECTIVE: This study aims to examine and contrast the perceptions of MS patients, neurologists, and palliative care physicians towards providing palliative care for patients with MS in Malaysia.

    METHODS: 12 MS patients, 5 neurologists, and 5 palliative care physicians participated in this qualitative study. Each participant took part in a semi-structured interview. The interviews were transcribed verbatim, and analysed using an iterative thematic analysis approach.

    RESULTS: Patients and neurologists mostly associated palliative care with the end-of-life and struggled to understand the need for palliative care in MS. Another barrier was the lack of understanding about the palliative care needs of MS patients. Palliative care physicians also identified the scarcity of resources and their lack of experience with MS as barriers. The current referral-based care pathway itself was found to be a barrier to the provision of palliative care.

    CONCLUSIONS: MS patients in Malaysia face several barriers in accessing palliative care. Overcoming these barriers will require improving the shared understanding of palliative care and its role in MS. The existing care pathway also needs to be reformed to ensure that it improves access to palliative care for MS patients.

  6. Ibrahim F, Mohan D, Sajab MS, Bakarudin SB, Kaco H
    Polymers (Basel), 2019 Sep 23;11(10).
    PMID: 31547544 DOI: 10.3390/polym11101544
    In this study, lignin has been extracted from oil palm empty fruit bunch (EFB) fibers via an organosolv process. The organosolv lignin obtained was defined by the presence of hydroxyl-containing molecules, such as guaiacyl and syringyl, and by the presence of phenolic molecules in lignin. Subsequently, the extracted organosolv lignin and graphene nanoplatelets (GNP) were utilized as filler and reinforcement in photo-curable polyurethane (PU), which is used in stereolithography 3D printing. The compatibility as well as the characteristic and structural changes of the composite were identified through the mechanical properties of the 3D-printed composites. Furthermore, the tensile strength of the composited lignin and graphene shows significant improvement as high as 27%. The hardness of the photo-curable PU composites measured by nanoindentation exhibited an enormous improvement for 0.6% of lignin-graphene at 92.49 MPa with 238% increment when compared with unmodified PU.
  7. Cheong WL, Mohan D, Warren N, Reidpath DD
    Disabil Rehabil, 2019 Nov 26.
    PMID: 31769306 DOI: 10.1080/09638288.2019.1695000
    Background: The needs of patients with multiple sclerosis have been well-studied in high-income, high-prevalence countries but few studies have been based in low- and middle-income countries where resources are relatively scarce. As such, little is known about the needs of patients living in these countries.Objective: The study seeks to develop an understanding of the needs of patients with multiple sclerosis living in Malaysia in order to generate insights and contribute to a global database of patients' experienceMethod: 12 patients with multiple sclerosis participated in this qualitative study and took part in a semi-structured interview. The interviews were transcribed and analysed using an iterative thematic analysis approach.Results: The experiences, challenges and needs of the patients were reported. Five themes were developed (Daily living, Financial, Emotional and psychological, Healthcare, and Family). These predominantly revolved around the struggles of coping and adapting to the symptoms and disabilities imposed by multiple sclerosis, their heavy reliance on personal finances to cope with the increased costs of living for themselves and their families, as well as the limited healthcare services and treatments available to help them to manage the physical and emotional symptoms of multiple sclerosis.Conclusion: Patients with multiple sclerosis in Malaysia have complex needs that are neglected due perceived lack of importance of the disease and the poor understanding of multiple sclerosis in general. Patients rely heavily on their finances to improve their quality of life. This perpetuates health inequities and reform of the national health financing system is needed to provide patients with the healthcare and support they need.Implications for rehabilitationPatients with multiple sclerosis in Malaysia prioritize being able to cope and adapt to their disabilities in order to continue performing their activities of daily living.There is a need to increase the availability and accessibility of healthcare professionals that are experienced with the management of multiple sclerosis.Healthcare professionals need to improve their understanding of the patients' needs and what they consider to be important in order to provide therapy that is effective and relevant.Patients also require financial support to help them with the increased costs of living associated with MS as well as the costs of healthcare services such as physiotherapy and rehabilitation.
  8. Mohan D, Stephan BC, Allotey P, Jagger C, Pearce M, Siervo M, et al.
    BMJ Open, 2017 01 19;7(1):e013635.
    PMID: 28104710 DOI: 10.1136/bmjopen-2016-013635
    INTRODUCTION: There is a growing proportion of population aged 65 years and older in low-income and middle-income countries. In Malaysia, this proportion is predicted to increase from 5.1% in 2010 to more than 15.4% by 2050. Cognitive ageing and dementia are global health priorities. However, risk factors and disease associations in a multiethnic, middle-income country like Malaysia may not be consistent with those reported in other world regions. Knowing the burden of cognitive impairment and its risk factors in Malaysia is necessary for the development of management strategies and would provide valuable information for other transitional economies.

    METHODS AND ANALYSIS: This is a community-based feasibility study focused on the assessment of cognition, embedded in the longitudinal study of health and demographic surveillance site of the South East Asia Community Observatory (SEACO), in Malaysia. In total, 200 adults aged ≥50 years are selected for an in-depth health and cognitive assessment including the Mini Mental State Examination, the Montreal Cognitive Assessment, blood pressure, anthropometry, gait speed, hand grip strength, Depression Anxiety Stress Score and dried blood spots.

    DISCUSSION AND CONCLUSIONS: The results will inform the feasibility, response rates and operational challenges for establishing an ageing study focused on cognitive function in similar middle-income country settings. Knowing the burden of cognitive impairment and dementia and risk factors for disease will inform local health priorities and management, and place these within the context of increasing life expectancy.

    ETHICS AND DISSEMINATION: The study protocol is approved by the Monash University Human Research Ethics Committee. Informed consent is obtained from all the participants. The project's analysed data and findings will be made available through publications and conference presentations and a data sharing archive. Reports on key findings will be made available as community briefs on the SEACO website.

  9. Reidpath DD, Soyiri I, Jahan NK, Mohan D, Ahmad B, Ahmad MP, et al.
    Int J Public Health, 2018 Mar;63(2):193-202.
    PMID: 29372287 DOI: 10.1007/s00038-017-1072-4
    OBJECTIVES: The lack of population-based evidence on the risk factors for poor glycaemic control in diabetics, particularly in resource-poor settings, is a challenge for the prevention of long-term complications. This study aimed to identify the metabolic and demographic risk factors for poor glycaemic control among diabetics in a rural community in Malaysia.

    METHODS: A total of 1844 (780 males and 1064 females) known diabetics aged ≥ 35 years were identified from the South East Asia Community Observatory (SEACO) health and demographic surveillance site database.

    RESULTS: 41.3% of the sample had poor glycaemic control. Poor glycaemic control was associated with age and ethnicity, with older participants (65+) better controlled than younger adults (45-54), and Malaysian Indians most poorly controlled, followed by Malay and then Chinese participants. Metabolic risk factors were also highly associated with poor glycaemic control.

    CONCLUSIONS: There is a critical need for evidence for a better understanding of the mechanisms of the associations between risk factors and glycaemic control.

  10. Yap KH, Mohan D, Stephan BCM, Warren N, Allotey P, Reidpath DD
    J Aging Res, 2019;2019:9151802.
    PMID: 31093373 DOI: 10.1155/2019/9151802
    Subjective memory complaints (SMCs) and social capital were known to be related to self-rated health (SRH). Despite this, no studies have examined the potential interaction of SMC and social capital on SRH. Using data from a cross-sectional health survey of men and women aged 56 years and above (n = 6,421), we examined how SMCs and social capital explained SRH in a population of community-dwelling older adults in a semirural area in Malaysia. We also evaluated whether SRH's relationship with SMCs is moderated by social capital. The association of SMC and social capital with poor SRH was investigated using multivariable logistic regression. Social capital (OR = 0.86, 95% CI = 0.82-0.89), mild SMC (OR = 1.70, 95% CI = 1.50-1.94), and moderate SMC (OR = 1.90, 95% CI = 1.63-2.20) were found to be associated with poor SRH after adjustment for sociodemographic factors and depression in the initial regression model. SMC was found to have partial interaction effects with social capital which was included in the subsequent regression model. Unlike individuals with no SMC and mild SMC, those who reported moderate SMC did not show decreasing probabilities of poor SRH despite increasing levels of social capital. Nevertheless, this analysis suggests that social capital and SMC are independent predictors of poor SRH. Further research needs to be targeted at improving the understanding on how social capital and SMC moderate and interact with the perception of health in older adults.
  11. Mohan D, Khairullah NF, How YP, Sajab MS, Kaco H
    Polymers (Basel), 2020 Apr 23;12(4).
    PMID: 32340327 DOI: 10.3390/polym12040986
    Drug delivery constitutes the formulations, technologies, and systems for the transport of pharmaceutical compounds to specific areas in the body to exert safe therapeutic effects. The main criteria for selecting the correct medium for drug delivery are the quantity of the drug being carried and the amount of time required to release the drug. Hence, this research aimed to improve the aforementioned criteria by synthesizing a medium based on calcium carbonate-nanocellulose composite and evaluating its efficiency as a medium for drug delivery. Specifically, the efficiency was assessed in terms of the rates of uptake and release of 5-fluorouracil. Through the evaluation of the morphological and chemical properties of the synthesized composite, the established 3D printing profiles of nanocellulose and CaCO3 took place following the layer-by-layer films. The 3D printed double laminated CaCO3-nanocellulose managed to release the 5-fluorouracil as an effective single composition and in a time-controlled manner.
  12. Mohan D, Sajab MS, Kaco H, Bakarudin SB, Noor AM
    Nanomaterials (Basel), 2019 Dec 03;9(12).
    PMID: 31817002 DOI: 10.3390/nano9121726
    The recognition of nanocellulose has been prominent in recent years as prospect materials, yet the ineffectiveness of nanocellulose to disperse in an organic solvent has restricted its utilization, especially as a reinforcement in polymer nanocomposite. In this study, cellulose has been isolated and defibrillated as cellulose nanofibrils (CNF) from oil palm empty fruit bunch (EFB) fibers. Subsequently, to enhance its compatibility with UV-curable polyurethane (PU)-based resin, the surface hydrophilicity of CNF has been tailored with polyethylene glycol (PEG), as well as reduced graphene oxide (rGO). The dispersibility of reinforced modified CNF in UV-curable PU was examined through the transmittance interruption of resin, chemical, and mechanical properties of the composite printed using the stereolithographic technique. Evidently, the enhanced compatibility of modified CNF and UV-curable PU was shown to improve the tensile strength and hardness of the composites by 37% and 129%, respectively.
  13. Sajab MS, Mohan D, Santanaraj J, Chia CH, Kaco H, Harun S, et al.
    Sci Rep, 2019 08 12;9(1):11703.
    PMID: 31406228 DOI: 10.1038/s41598-019-48274-2
    The recognition of cellulose nanofibrils (CNF) in the past years as a high prospect material has been prominent, but the impractical cellulose extraction method from biomass remained as a technological barrier for industrial practice. In this study, the telescopic approach on the fractionation of lignin and cellulose was performed by organosolv extraction and catalytic oxidation from oil palm empty fruit bunch fibers. The integration of these techniques managed to synthesize CNF in a short time. Aside from the size, the zeta potential of CNF was measured at -41.9 mV, which allow higher stability of the cellulose in water suspension. The stability of CNF facilitated a better dispersion of Fe(0) nanoparticles with the average diameter size of 52.3-73.24 nm through the formulation of CNF/Fe(0). The total uptake capacity of CNF towards 5-fluorouracil was calculated at 0.123 mg/g. While the synergistic reactions of adsorption-oxidation were significantly improved the removal efficacy three to four times greater even at a high concentration of 5-fluorouracil. Alternatively, the sludge generation after the oxidation reaction was completely managed by the encapsulation of Fe(0) nanoparticles in regenerated cellulose.
  14. Kongpakwattana K, Dejthevaporn C, Krairit O, Dilokthornsakul P, Mohan D, Chaiyakunapruk N
    Value Health, 2019 10;22(10):1137-1145.
    PMID: 31563256 DOI: 10.1016/j.jval.2019.04.1937
    BACKGROUND: Although an increase in the burden of Alzheimer's disease (AD) is evident worldwide, knowledge of costs and health-related quality of life (HRQOL) associated with AD in low- and middle-income countries is still lacking.

    OBJECTIVES: This study aimed to collect real-world cost and HRQOL data, and investigate their associations with multiple disease-severity indicators among AD patients in Thailand.

    METHODS: We recruited AD patients aged ≥60 years accompanied by their caregivers at a university-affiliated tertiary hospital. A one-time structured interview was conducted to collect disease-severity indicators, HRQOL, and caregiving information using standardized tools. The hospital's database was used to retrieve healthcare resource utilization occurred over 6 months preceding the interview date. Costs were annualized and stratified based on cognitive status. Generalized linear models were employed to evaluate determinants of costs and HRQOL.

    RESULTS: Among 148 community-dwelling patients, average annual total societal costs of AD care were $8014 (95% confidence interval [CI]: $7295-$8844) per patient. Total costs of patients with severe stage ($9860; 95% CI: $8785-$11 328) were almost twice as high as those of mild stage ($5524; 95% CI: $4649-$6593). The major cost driver was direct medical costs, particularly those incurred by AD prescriptions. Functional status was the strongest determinant for both total costs and patient's HRQOL (P value

  15. Stephan BCM, Pakpahan E, Siervo M, Licher S, Muniz-Terrera G, Mohan D, et al.
    Lancet Glob Health, 2020 Apr;8(4):e524-e535.
    PMID: 32199121 DOI: 10.1016/S2214-109X(20)30062-0
    BACKGROUND: To date, dementia prediction models have been exclusively developed and tested in high-income countries (HICs). However, most people with dementia live in low-income and middle-income countries (LMICs), where dementia risk prediction research is almost non-existent and the ability of current models to predict dementia is unknown. This study investigated whether dementia prediction models developed in HICs are applicable to LMICs.

    METHODS: Data were from the 10/66 Study. Individuals aged 65 years or older and without dementia at baseline were selected from China, Cuba, the Dominican Republic, Mexico, Peru, Puerto Rico, and Venezuela. Dementia incidence was assessed over 3-5 years, with diagnosis according to the 10/66 Study diagnostic algorithm. Discrimination and calibration were tested for five models: the Cardiovascular Risk Factors, Aging and Dementia risk score (CAIDE); the Study on Aging, Cognition and Dementia (AgeCoDe) model; the Australian National University Alzheimer's Disease Risk Index (ANU-ADRI); the Brief Dementia Screening Indicator (BDSI); and the Rotterdam Study Basic Dementia Risk Model (BDRM). Models were tested with use of Cox regression. The discriminative accuracy of each model was assessed using Harrell's concordance (c)-statistic, with a value of 0·70 or higher considered to indicate acceptable discriminative ability. Calibration (model fit) was assessed statistically using the Grønnesby and Borgan test.

    FINDINGS: 11 143 individuals without baseline dementia and with available follow-up data were included in the analysis. During follow-up (mean 3·8 years [SD 1·3]), 1069 people progressed to dementia across all sites (incidence rate 24·9 cases per 1000 person-years). Performance of the models varied. Across countries, the discriminative ability of the CAIDE (0·52≤c≤0·63) and AgeCoDe (0·57≤c≤0·74) models was poor. By contrast, the ANU-ADRI (0·66≤c≤0·78), BDSI (0·62≤c≤0·78), and BDRM (0·66≤c≤0·78) models showed similar levels of discriminative ability to those of the development cohorts. All models showed good calibration, especially at low and intermediate levels of predicted risk. The models validated best in Peru and poorest in the Dominican Republic and China.

    INTERPRETATION: Not all dementia prediction models developed in HICs can be simply extrapolated to LMICs. Further work defining what number and which combination of risk variables works best for predicting risk of dementia in LMICs is needed. However, models that transport well could be used immediately for dementia prevention research and targeted risk reduction in LMICs.

    FUNDING: National Institute for Health Research, Wellcome Trust, WHO, US Alzheimer's Association, and European Research Council.

  16. Savell E, Gilmore AB, Sims M, Mony PK, Koon T, Yusoff K, et al.
    Bull. World Health Organ., 2015 Dec 01;93(12):851-61G.
    PMID: 26668437 DOI: 10.2471/BLT.15.155846
    OBJECTIVE: To examine and compare tobacco marketing in 16 countries while the Framework Convention on Tobacco Control requires parties to implement a comprehensive ban on such marketing.

    METHODS: Between 2009 and 2012, a kilometre-long walk was completed by trained investigators in 462 communities across 16 countries to collect data on tobacco marketing. We interviewed community members about their exposure to traditional and non-traditional marketing in the previous six months. To examine differences in marketing between urban and rural communities and between high-, middle- and low-income countries, we used multilevel regression models controlling for potential confounders.

    FINDINGS: Compared with high-income countries, the number of tobacco advertisements observed was 81 times higher in low-income countries (incidence rate ratio, IRR: 80.98; 95% confidence interval, CI: 4.15-1578.42) and the number of tobacco outlets was 2.5 times higher in both low- and lower-middle-income countries (IRR: 2.58; 95% CI: 1.17-5.67 and IRR: 2.52; CI: 1.23-5.17, respectively). Of the 11,842 interviewees, 1184 (10%) reported seeing at least five types of tobacco marketing. Self-reported exposure to at least one type of traditional marketing was 10 times higher in low-income countries than in high-income countries (odds ratio, OR: 9.77; 95% CI: 1.24-76.77). For almost all measures, marketing exposure was significantly lower in the rural communities than in the urban communities.

    CONCLUSION: Despite global legislation to limit tobacco marketing, it appears ubiquitous. The frequency and type of tobacco marketing varies on the national level by income group and by community type, appearing to be greatest in low-income countries and urban communities.

  17. Chan KY, Adeloye D, Asante KP, Calia C, Campbell H, Danso SO, et al.
    J Glob Health, 2019 Dec;9(2):020103.
    PMID: 31893025 DOI: 10.7189/jogh.09.020103
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