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Processus de coconstruction d’une intervention visant à intégrer l’approche palliative à l’unité de soins intensifs

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... Les différentes variantes de la théorie ancrée et des types d'analyse, l'étude de cas, l'anasynthèse (Messier & Dumais, 2016), la phénoménologie (Guimont-Plourde, 2013), la praxéologie (Houle et al., 2013), l'ethnographie (Caron et al., 2017;Felices-Luna, 2015;Niang Dupéré, & Fletcheat, 2017), la recherche-action ou la recherche participative (Guay et al., 2017;Roy, Damant, Chbat, Johnson, & Gervais, 2016) et les récits biographiques (Garneau, 2015) en sont d'intéressantes illustrations. Les chercheurs y discutent à la fois de leur rôle, présentent leur recherche en la situant dans l'ensemble des textes fondateurs et s'appuient sur des procédures qui ont fait leurs preuves. ...
... Les chercheuses démontrent ainsi la pertinence d'inclure un objectif de documentation du processus de recherche afin de contribuer aux connaissances sur la recherche-action participative et sa crédibilité dans l'évaluation de programmes. Il en est de même pour le travail de Guay et al. (2017) sur l'intégration d'une approche palliative dans une unité de soins intensifs. Au travers de la description d'une recherche participative, ces chercheurs illustrent la coconstruction d'une intervention qui respecte les principes-clés de la recherche-action, à savoir « la démocratie, la participation et l'appropriation du processus de recherche » (p. ...
... Nous procédons également selon une logique de recherche basée sur le design (Design-Based Research (DBR)) (Bell, 2004 ;Sandoval et Bell, 2004 ;Wang et Hannafin, 2005;Herrington et al., 2007). Celle-ci s'inscrit dans l'esprit de la méthodologie de recherche- (Roy et Prévost, 2013, p.129), la recherche-action constitue une forme de recherche participative qui a pour fondements la coconstruction des connaissances, la proximité chercheurs-praticiens-acteurs et le cycle itératif action-implantation-réflexionévaluation (Guay, Michaud et Mathieu, 2017). ...
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Research about collaboration within teams of learners in intensive care is sparse, as is research on how the learners in a group develop into a team. The aim of this study was to explore the collaboration in teams of learners during a rotation in an interprofessional education unit in intensive care from a sociocultural learning perspective. Focused Ethnographic methods were used to collect data following eight teams of learners in 2009 and 2010. Each team consisted of one resident, one specialist nurse student and their supervisors (n = 28). The material consisted of 100 hours of observations, interviews, and four hours of sound recordings. A qualitative analysis explored changing patterns of interplay through a constant comparative approach. The learners’ collaboration progressed along a pattern of participation common to all eight groups with a chronological starting point and an end point. The progress consisted of three main steps where the learners’ groups developed into teams during a week’s training. The supervisors’ guided the progress by gradually stepping back to provide latitude for critical reflection and action. Our main conclusion in training teams of learners how to collaborate in the intensive care is the crucial understanding of how to guide them to act like a team, feel like a team and having the authority to act as a team.
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Participatory action research (PAR) is a methodological stance that researchers can find both inspiring and daunting. Community-based PAR offers a platform by which social scientists can contribute to the democratization of knowledge and its production, but also requires that they go beyond conventional roles and procedures to interact with community co-researchers in ways that may leave university-based researchers feeling exposed and rudderless. In this article, the authors present episodes from three different PAR projects that illustrate some of the challenges that PAR presents for university-based researchers, as well as what can be learned from them.
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We systematically reviewed ICU-based knowledge translation studies to assess the impact of knowledge translation interventions on processes and outcomes of care. We searched electronic databases (to July, 2010) without language restrictions and hand-searched reference lists of relevant studies and reviews. Two reviewers independently identified randomized controlled trials and observational studies comparing any ICU-based knowledge translation intervention (e.g., protocols, guidelines, and audit and feedback) to management without a knowledge translation intervention. We focused on clinical topics that were addressed in greater than or equal to five studies. Pairs of reviewers abstracted data on the clinical topic, knowledge translation intervention(s), process of care measures, and patient outcomes. For each individual or combination of knowledge translation intervention(s) addressed in greater than or equal to three studies, we summarized each study using median risk ratio for dichotomous and standardized mean difference for continuous process measures. We used random-effects models. Anticipating a small number of randomized controlled trials, our primary meta-analyses included randomized controlled trials and observational studies. In separate sensitivity analyses, we excluded randomized controlled trials and collapsed protocols, guidelines, and bundles into one category of intervention. We conducted meta-analyses for clinical outcomes (ICU and hospital mortality, ventilator-associated pneumonia, duration of mechanical ventilation, and ICU length of stay) related to interventions that were associated with improvements in processes of care. From 11,742 publications, we included 119 investigations (seven randomized controlled trials, 112 observational studies) on nine clinical topics. Interventions that included protocols with or without education improved continuous process measures (seven observational studies and one randomized controlled trial; standardized mean difference [95% CI]: 0.26 [0.1, 0.42]; p = 0.001 and four observational studies and one randomized controlled trial; 0.83 [0.37, 1.29]; p = 0.0004, respectively). Heterogeneity among studies within topics ranged from low to extreme. The exclusion of randomized controlled trials did not change our results. Single-intervention and lower-quality studies had higher standardized mean differences compared to multiple-intervention and higher-quality studies (p = 0.013 and 0.016, respectively). There were no associated improvements in clinical outcomes. Knowledge translation interventions in the ICU that include protocols with or without education are associated with the greatest improvements in processes of critical care.
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Professional organizations, consensus groups, and stakeholders are calling for better palliative care in acute care settings, particularly in ICUs. Our ability to deliver that care is dependent on the outcomes associated with palliative care in the ICU. This review provides a conceptual framework for these outcomes, discusses current and future challenges for work in this field, and advocates for better use of patient-centered outcomes in future studies. Previous studies of palliative care interventions in the ICU have used heterogeneous outcomes, conceptualized as: systems-related, content-related, clinician-related, or patient/family-related. Few outcomes were used in multiple studies and many studies had insufficient power and questionable generalizability and impact. Although nearly all previous studies incorporated family-related outcomes, not one incorporated patient-centered outcomes, such as health-related quality of life, patient symptom score, or consensus between patient goals and care provided. Delivery of palliative care in the ICU will be hampered until studies incorporate outcomes that are: responsive to and reflective of variations in care, and multi-faceted (with patient-centered components) to reflect the multi-dimensional nature of palliative care and the varied needs of different stakeholders.
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Palliative care, a medical field that has been practiced informally for centuries, was recently granted formal specialty status by the American Board of Medical Specialties. The demand for palliative care specialists is growing rapidly, since timely palliative care consultations have been shown to improve the quality of care, reduce overall costs, and sometimes even increase longevity.1,2 The field grew out of a hospice tradition in which palliative treatment was delivered only at the end of life, but its role has expanded so that palliative care specialists now also provide palliative treatment in the earlier stages of disease alongside disease-directed . . .
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Importance A recent Centers for Disease Control and Prevention report found that more persons die at home. This has been cited as evidence that persons dying in the United States are using more supportive care. Objective To describe changes in site of death, place of care, and health care transitions between 2000, 2005, and 2009. Design, Setting, and Patients Retrospective cohort study of a random 20% sample of fee-for-service Medicare beneficiaries, aged 66 years and older, who died in 2000 (n = 270 202), 2005 (n = 291 819), or 2009 (n = 286 282). A multivariable regression model examined outcomes in 2000 and 2009 after adjustment for sociodemographic characteristics. Based on billing data, patients were classified as having a medical diagnosis of cancer, chronic obstructive pulmonary disease, or dementia in the last 180 days of life. Main Outcome Measures Site of death, place of care, rates of health care transitions, and potentially burdensome transitions (eg, health care transitions in the last 3 days of life). Results Our random 20% sample included 848 303 fee-for-service Medicare decedents (mean age, 82.3 years; 57.9% female, 88.1% white). Comparing 2000, 2005, and 2009, the proportion of deaths in acute care hospitals decreased from 32.6% (95% CI, 32.4%-32.8%) to 26.9% (95% CI, 26.7%-27.1%) to 24.6% (95% CI, 24.5%-24.8%), respectively. However, intensive care unit (ICU) use in the last month of life increased from 24.3% (95% CI, 24.1%-24.5%) to 26.3% (95% CI, 26.1%-26.5%) to 29.2% (95% CI, 29.0%-29.3%). (Test of trend P value was <.001 for each variable.) Hospice use at the time of death increased from 21.6% (95% CI, 21.4%-21.7%) to 32.3% (95% CI, 32.1%-32.5%) to 42.2% (95% CI, 42.0%-42.4%), with 28.4% (95% CI, 27.9%-28.5%) using a hospice for 3 days or less in 2009. Of these late hospice referrals, 40.3% (95% CI, 39.7%-40.8%) were preceded by hospitalization with an ICU stay. The mean number of health care transitions in the last 90 days of life increased from 2.1 (interquartile range [IQR], 0-3.0) to 2.8 (IQR, 1.0-4.0) to 3.1 per decedent (IQR, 1.0-5.0). The percentage of patients experiencing transitions in the last 3 days of life increased from 10.3% (95% CI, 10.1%-10.4%) to 12.4% (95% CI, 12.3%-2.5%) to 14.2% (95% CI, 14.0%-14.3%). Conclusion and Relevance Among Medicare beneficiaries who died in 2009 and 2005 compared with 2000, a lower proportion died in an acute care hospital, although both ICU use and the rate of health care transitions increased in the last month of life.
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The interactions and observations of residents speaking with patients and family members about end-of-life decisions indicated a need for more empathy. Nursing and medical students have been called to learn and work together so they can work more effectively. A review of the evidence on interdisciplinary education of residents concerning end-of-life care and communicating with patients and their family members was the inspiration for this study. This article applies evidence related to interdisciplinary education in critical care settings. This pilot project was a collaboration of medical education between a critical care service in a public hospital and baccalaureate nursing students assisting family members in making end-of-life decisions. As nursing students, we were able to effectively present content on end-of-life decision making to medical residents.
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The randomized controlled trial is seen by many as the summit of evidence-based medicine, yet, in the intensive care unit, randomized controlled trials can be challenging to conduct, and results are often difficult to interpret and apply. Many randomized controlled trials in intensive care patients have not demonstrated beneficial effects of the intervention under investigation often despite good preclinical and even previous randomized controlled trial evidence. There are many reasons for these negative results including problems with timing, end point selection, and heterogeneous populations. In this article, we will discuss the limitations of randomized controlled trials in the intensive care unit population and highlight the importance of considering other study designs in the challenging intensive care unit environment.
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A gap exists between best evidence and best practice in intensive care units. The aim of this study was to investigate different aspects of intensive care nurses' and physicians' inter- and intraprofessional collaboration, with focus on factors associated with standardised weaning from mechanical ventilation. A qualitative design was used for implementing research-based knowledge into multistage focus group discussions. Data were analysed by means of qualitative content analysis. One main theme emerged: The need for strategies aimed at improving quality control of care, and three sub-themes: 'Interprofessional learning', 'Quality control of care', and 'Teamwork and communication'. The multistage focus groups were perceived as an important interprofessional arena for improving quality of care. Improvement projects and research dissemination must be regarded as vital parts of the organisation's ongoing development work. Management was perceived as crucial for success. Interprofessional research dissemination was perceived as important both in the creation of a common understanding and in knowledge development. Managers should make use of the valuable knowledge possessed by bedside professionals in their strategic planning. There is a need to allocate time for learning and reflection to provide a safe practice environment.
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There is a growing literature on the relationship between teamwork and patient outcomes in intensive care, providing new insights into the skills required for effective team performance. The purpose of this review is to consolidate the most robust findings from this research into an intensive care unit (ICU) team performance framework. Studies investigating teamwork within the ICU using PubMed, Science Direct, and Web of Knowledge databases. Studies investigating the relationship between aspects of teamwork and ICU outcomes, or studies testing factors that are found to influence team working in the ICU. Teamwork behaviors associated with patient or staff-related outcomes in the ICU were identified. Teamwork behaviors were grouped according to the team process categories of "team communication," "team leadership," "team coordination," and "team decision making." A prototype framework explaining the team performance in the ICU was developed using these categories. The purpose of the framework is to consolidate the existing ICU teamwork literature and to guide the development and testing of interventions for improving teamwork. Effective teamwork is shown as crucial for providing optimal patient care in the ICU. In particular, team leadership seems vital for guiding the way in which ICU team members interact and coordinate with others.
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Qualitative research and its methods stem from the social sciences and can be used to describe and interpret complex phenomena that involve individuals' views, beliefs, preferences, and subjective responses to places and people. Thus, qualitative research explores the many subjective factors that may influence patient outcomes, staff well-being, and healthcare quality, yet fail to lend themselves to the hypothesis-testing approach that characterizes quantitative research. Qualitative research is valuable in the intensive care unit to explore organizational and cultural issues and to gain insight into social interactions, healthcare delivery processes, and communication. Qualitative research generates explanatory models and theories, which can then serve to devise interventions, whose efficacy can be studied quantitatively. Thus, qualitative research works synergistically with quantitative research, providing new impetus to the research process and a new dimension to research findings. Qualitative research starts with conceptualizing the research question, choosing the appropriate qualitative strategy, and designing the study; rigorous methods specifically designed for qualitative research are then used to conduct the study, analyze the data, and verify the findings. The researcher is the data-collecting instrument, and the data are the participants' words and behaviors. Data coding methods are used to describe experiences, discover themes, and build theories. In this review, we outline the rationale and methods for conducting qualitative research to inform critical care issues. We provide an overview of available qualitative methods and explain how they can work in close synergy with quantitative methods. To illustrate the effectiveness of combining different research methods, we will refer to recent qualitative studies conducted in the intensive care unit.
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The primary goal of this study was to address the documented deficiencies in end-of-life care (EOLC) in intensive care unit settings by identifying key EOLC domains and related quality indicators for use in the intensive care unit through a consensus process. A second goal was to propose specific clinician and organizational behaviors and interventions that might be used to improve these EOLC quality indicators. Participants were the 36 members of the Robert Wood Johnson Foundation (RWJF) Critical Care End-of-Life Peer Workgroup and 15 nurse-physician teams from 15 intensive care units affiliated with the work group members. Fourteen adult medical, surgical, and mixed intensive care units from 13 states and the District of Columbia in the United States and one mixed intensive care unit in Canada were represented. An in-depth literature review was conducted to identify articles that assessed the domains of quality of EOLC in the intensive care unit and general health care. Consensus regarding the key EOLC domains in the intensive care unit and quality performance indicators within each domain was established based on the review of the literature and an iterative process involving the authors and members of the RWJF Critical Care End-of-Life Peer Workgroup. Specific clinician and organizational behaviors and interventions to address the proposed EOLC quality indicators within the domains were identified through a collaborative process with the nurse-physician teams in 15 intensive care units. Seven EOLC domains were identified for use in the intensive care unit: a) patient- and family-centered decision making; b) communication; c) continuity of care; d) emotional and practical support; e) symptom management and comfort care; f) spiritual support; and g) emotional and organizational support for intensive care unit clinicians. Fifty-three EOLC quality indicators within the seven domains were proposed. More than 100 examples of clinician and organizational behaviors and interventions that could address the EOLC quality indicators in the intensive care unit setting were identified. These EOLC domains and the associated quality indicators, developed through a consensus process, provide clinicians and researchers with a framework for understanding quality of EOLC in the intensive care unit. Once validated, these indicators might be used to improve the quality of EOLC by serving as the components of an internal or external audit evaluating EOLC continuous quality improvement efforts in intensive care unit settings.
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The call for evidence-based practice presents numerous challenges to nurses who are responsible for developing interventions and expanding the associated knowledge base. The challenge is compounded because there is limited literature concerning development of interventions and their evidence base. The purpose of this article is to present a model that has been successfully used to guide the process of developing and testing complex nursing interventions, especially those in which the experience of the client plays an important role. The model consists of four stages: problem definition, accumulation of building blocks for intervention design, intervention design and intervention validation. Each stage is described and examples from research studies are presented. Specific attention is given to the manner in which the model allows for the accumulation of empirical evidence and theory development during the development process. Use of the model could facilitate effective communication among nurses, researchers and educators when discussing the development and testing of nursing interventions.
Article
To develop clinical practice guidelines for the support of the patient and family in the adult, pediatric, or neonatal patient-centered ICU. A multidisciplinary task force of experts in critical care practice was convened from the membership of the American College of Critical Care Medicine (ACCM) and the Society of Critical Care Medicine (SCCM) to include representation from adult, pediatric, and neonatal intensive care units. The task force members reviewed the published literature. The Cochrane library, Cinahl, and MedLine were queried for articles published between 1980 and 2003. Studies were scored according to Cochrane methodology. Where evidence did not exist or was of a low level, consensus was derived from expert opinion. The topic was divided into subheadings: decision making, family coping, staff stress related to family interactions, cultural support, spiritual/religious support, family visitation, family presence on rounds, family presence at resuscitation, family environment of care, and palliative care. Each section was led by one task force member. Each section draft was reviewed by the group and debated until consensus was achieved. The draft document was reviewed by a committee of the Board of Regents of the ACCM. After steering committee approval, the draft was approved by the SCCM Council and was again subjected to peer review by this journal. More than 300 related studies were reviewed. However, the level of evidence in most cases is at Cochrane level 4 or 5, indicating the need for further research. Forty-three recommendations are presented that include, but are not limited to, endorsement of a shared decision-making model, early and repeated care conferencing to reduce family stress and improve consistency in communication, honoring culturally appropriate requests for truth-telling and informed refusal, spiritual support, staff education and debriefing to minimize the impact of family interactions on staff health, family presence at both rounds and resuscitation, open flexible visitation, way-finding and family-friendly signage, and family support before, during, and after a death.
Article
The question of who should direct the care of critically ill patients is both multifaceted and timely. Currently, only about 30% of critical care units in the United States are staffed by dedicated intensivists. This number is likely to increase as groups such as Leapfrog financially reward hospitals that have dedicated intensivists around the clock. The problem, however, is that the supply of intensivists by training is not projected to increase, whereas the demand for health care, by all accounts, will significantly increase in the near future. There is an increasing body of literature suggesting not only morbidity and mortality benefits but decreased length of stay and profound cost savings when a team directed by critical care physicians cares for patients in the intensive care unit. Despite this, many have argued that a consultant-based unit (so called open unit) is less alienating to a patient's primary care physician or surgeon and promotes continuity of care. In addition, although much of the literature has suggested purported benefit derived from a dedicated intensivist staffing model, little has been published regarding optimal intensivist/patient ratios. If dedicated critical care teams decrease complications in the intensive care unit, one may logically reason that as the intensivist/patient ratio decreases, morbidity or mortality, or both, might increase. This, however, has not yet been shown. This article will address many of these issues, discuss the history of critical care medicine in the United States, and review the pertinent literature. With the projected shortage of critical care-trained physicians and an increasingly aging population, it is imperative that health professionals evaluate this issue sooner rather than later.
Article
Traditional goals of critical care center on curative interventions for patients with acute illness. However, death is a common occurrence in critical care, which means a shift from curative care to comfort care. For a number of reasons, the transition in care is often not a smooth one. An integrated literature review was completed on 22 studies related to provision of terminal care. These 13 quantitative studies along with 9 qualitative studies identified specific barriers to effective terminal care provision including (a) lack of involvement in the plan of care and comfort, (b) disagreement among physicians and other healthcare team members, (c) inadequacy of pain relief, (d) unrealistic expectations of families, (e) nurses' difficulty coping, (f) lack of experience and education, (g) staffing levels, and (h) environmental circumstances. Recommendations address strategies to improve terminal care and suggest future research needed.
Article
Evaluating interventions in palliative care using randomized controlled trials (RCTs) has helped advance the specialty and create an evidence base for the delivery of care. RCTs, however, are notoriously difficult to conduct in palliative care, raising a variety of practical, ethical and moral dilemmas. Mixed-methods research, which combines qualitative research and RCTs, offers a potential solution to these problems. This paper begins by examining the theoretical basis for combining the two approaches, before reviewing the specific role qualitative research could play in planning, conducting and implementing trials. The paper then goes on to explore how palliative care research currently uses the mixed-methods approach, by searching the trials included in six Cochrane Systematic Reviews (n = 146) on the incorporation of qualitative research. Only one trial undertook qualitative research. These findings reflect some of the challenges facing mixed-methods research, which include lack of experience in a research team, the problems of obtaining funding and difficulties in publishing. The paper concludes that while combining qualitative and quantitative research is not a panacea for methodological problems in palliative care research, with careful planning and integration, the approach may enhance the clinical and ethical utility of trial findings, which in turn will improve patient care.
Article
To determine how many multicenter, randomized controlled trials have been published that assess mortality as a primary outcome in the adult intensive care unit population, and to evaluate their methodologic quality. A sensitive search strategy for randomized controlled trials was conducted in the Cochrane Central Register of Controlled Trials and in MedLine using the PubMed interface. All publications of adult, multicenter randomized controlled trials carried out in the intensive care unit, with mortality as a primary outcome, and including >50 patients were selected. Seventy-two randomized controlled trials were retrieved and were classified according to their effect on mortality: beneficial, detrimental, or neutral. Ten of the studies reported a positive impact of the studied intervention on mortality, seven studies reported a detrimental effect of the intervention, and 55 studies showed no effect on mortality. This literature search demonstrates that relatively few of the randomized controlled trials conducted in intensive care units and using mortality as a primary outcome show a beneficial impact of the intervention on the survival of critically ill patients. Methodological limitations of some of the randomized controlled trials may have prevented positive results. Other forms of evidence and end points other than mortality need to be considered when evaluating interventions in critically ill patients.
Article
Background: These recommendations have been developed to improve the care of intensive care unit (ICU) patients during the dying process. The recommendations build on those published in 2003 and highlight recent developments in the field from a U.S. perspective. They do not use an evidence grading system because most of the recommendations are based on ethical and legal principles that are not derived from empirically based evidence. Principal findings: Family-centered care, which emphasizes the importance of the social structure within which patients are embedded, has emerged as a comprehensive ideal for managing end-of-life care in the ICU. ICU clinicians should be competent in all aspects of this care, including the practical and ethical aspects of withdrawing different modalities of life-sustaining treatment and the use of sedatives, analgesics, and nonpharmacologic approaches to easing the suffering of the dying process. Several key ethical concepts play a foundational role in guiding end-of-life care, including the distinctions between withholding and withdrawing treatments, between actions of killing and allowing to die, and between consequences that are intended vs. those that are merely foreseen (the doctrine of double effect). Improved communication with the family has been shown to improve patient care and family outcomes. Other knowledge unique to end-of-life care includes principles for notifying families of a patient's death and compassionate approaches to discussing options for organ donation. End-of-life care continues even after the death of the patient, and ICUs should consider developing comprehensive bereavement programs to support both families and the needs of the clinical staff. Finally, a comprehensive agenda for improving end-of-life care in the ICU has been developed to guide research, quality improvement efforts, and educational curricula. Conclusions: End-of-life care is emerging as a comprehensive area of expertise in the ICU and demands the same high level of knowledge and competence as all other areas of ICU practice.
Fondements et étapes du processus de la recherche; méthodes quantitatives et qualitatives (3e éd.). Montréal : Chenelière Éducation
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Models for structuring a clinical initiative to enhance palliative care in the intensive care unit : A report from the IPAL-ICU
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