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ARTICLE
Effectiveness of Gun-Safety Counseling
and a Gun Lock Giveaway in a Hispanic Community
Paul S. Carbone, MD; Conrad J. Clemens, MD, MPH; Thomas M. Ball, MD, MPH
Objective:To evaluate the effectiveness of gun-safety
counseling, a gun-safety brochure, and a free gun lock
in subsequent gun removal and safe storage.
Methods:In a predominantly Hispanic pediatric clinic,
gun-owning families were identified and assigned to either
an intervention group (gun-safety counseling, gun-
safety brochure, and a free gun lock) or a control group
(usual anticipatory guidance). Families were resur-
veyed 1 month later for changes in the proportion of gun
owners, changes in frequency of unloaded and locked gun
storage, and changes to the use of locked storage.
Results:Two hundred six (7.8%) of the 2649 parents
initially surveyed kept guns in their households. At follow-
up, 16% of the control group removed all guns from their
homes as compared with 22% of the intervention group
(P=.41).Amongthefamilieswhoreceivedtheinterven-
tion, 61.6% either removed all guns from their homes or
improved their gun storage safety practice in some way.
Only 26.9% of the families in the control group showed
similar types of improvement (P!.001). In those house-
holds still with guns at follow-up, 50.9% of the inter-
vention group had some type of improvement in safe gun
storage compared with 12.3% of the control group
(P!.001). More specifically, 25.0% in the intervention
group improved the frequency of locked storage of guns
compared with 4.8% of those in the control group
(P=.003). Twenty-six percent of the intervention group
improved the use of locked storage compared with 3.1%
in the control group (P!.001).
Conclusions:Abriefgun-safetycounselingsessionsup-
ported with written information along with a gun lock
giveaway resulted in significant improvements in safe gun
storage behaviors. It did not significantly influence the
removal of guns from the home. This study gives sup-
port to the recommendations of the American Academy
of Pediatrics (Elk Grove Village, Ill) and other profes-
sional organizations to discuss gun safety with families
and encourages research in this area. It also suggests that
providing tools such as gun locks to enable the desired
behavior may improve safe storage.
Arch Pediatr Adolesc Med. 2005;159:1049-1054
GUN-RELATED DEATH AND
injury are a major public
health problem in the
United States, resulting in
tremendous losses to so-
ciety, especially in the pediatric and young
adult population. In 2001, 2937 children and
teenagers died as a result of gun-related in-
juries. Sixty-one percent of all gun-related
deaths among children were the result of ho-
micide and 32% were attributed to suicide.1
Gun ownership has been identified as a risk
factor for homicide and suicide in the home.2,3
The American Academy of Pediatrics (Elk
Grove Village, Ill) recommends violence pre-
vention anticipatory guidance at every health
maintenance visit, including urging gun re-
moval from homes.4The American Academy
of Pediatrics also supported the evaluation
of safe storage techniques such as lock boxes
and gun locks.5
Pediatricians agree that handguns in
the home are hazardous and that steps
should be taken to reduce this hazard
through legislation and parent counsel-
ing.6Children attending public urban
pediatric clinics are exposed to guns in
their homes, and their parents appear to
be receptive to gun-safety counseling.7
A significant percentage of gun-owning
parents store their guns loaded or un-
locked, substantially underestimating the
risk of injury to their children.8Yet
despite these facts, most practitioners fail
to counsel on gun safety with only 1 in 5
counseling more than 10% of their pa-
tient families.9
In spite of these recommendations, cur-
rent evidence generally does not support
gun-safety counseling. Previous studies of
gun-safety counseling in a pediatric out-
For editorial comment
see page 1081
Author Affiliations: Children’s
Primary Care Medical Group,
San Diego, Calif (Dr Carbone);
and Department of Pediatrics
and Steele Memorial Research
Center, University of Arizona,
Tucson (Drs Clemens and Ball).
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patient setting have not shown significant changes in
household gun ownership or storage patterns.10,11
Furthermore, gun-safety counseling as well as gun
ownership patterns in the Hispanic population have been
understudied. The impact of gun-related morbidity and
mortality on the Hispanic community is disproportion-
ately high when compared with the population as a whole.
Hispanic people are far less likely to own guns12 yet are
murdered with guns at rates second only to those for black
people. Gun homicide was the leading cause of death for
Hispanic people aged 15 to 34 years.1The data suggest
that efforts to prevent gun injury and death should fo-
cus special attention on minority populations.
Our objective was to determine the effectiveness of a
single, brief gun-safety counseling session within the con-
text of a pediatric visit that was then reinforced with writ-
ten material and a donated gun lock.
METHODS
SITE
This study was conducted at a pediatric clinic within the El Rio
Community Health Center in Tucson, Ariz. This urban com-
munity health center is the largest of its kind in the state and
the 29th largest in the United States. The El Rio Community
Health Center serves a population that is approximately 85%
minority (59% Hispanic, 16% unreported, 14% white, 8.6% Na-
tive American, 2% African American, 0.4% Asian or Pacific Is-
lander).
SUBJECT SELECTION
At check-in, all parents of children younger than 18 years old
were asked by the bilingual front-office staff to complete an
anonymous safety questionnaire in English or Spanish for a study
being conducted at the clinic. Along with general safety ques-
tions and basic demographic information, the questionnaire con-
tained embedded questions that specifically addressed gun own-
ership, type and frequency of gun storage, and whether or not
the gun was kept loaded. Respondents were screened for gun
ownership with the question, “Is there a gun (handgun or rifle)
currently kept in your household?” Questions that were not
simply yes/no responses used a 4-point Likert scale (never, some
of the time, most of the time, always). Pertinent questions re-
lating to guns contained in the questionnaire are listed in
Table 1. Upon receiving the completed baseline safety ques-
tionnaire back from the parent, a member of the front-office
staff reviewed it only to ascertain whether the parent was a gun
owner. Families not owning guns were excluded from study
participation. Informed consent was obtained in the parent’s
preferred language from gun-owning families willing to par-
ticipate in the study. A family could participate only once in
the study.
DESIGN
The study used a nonconcurrent, controlled pretest-posttest de-
sign. The control group was recruited prior to the interven-
tion group and prior to the providers having any specific knowl-
edge of the study. Previous studies have shown that few providers
perform regular gun-safety counseling,9so we assumed that very
few families in the control group received counseling. After the
recruitment of the control group, the providers were given train-
ing in gun-safety counseling. The training was facilitated by 1
of us (P.S.C.) using the program Steps to Prevent Firearm In-
jury in the Home (STOP 2).13 All of the 9 possible providers
during the study period were board-certified pediatricians and
all chose to participate in the study.
The program STOP 2 was designed for all health care pro-
viders across disciplines who work with diverse patient popu-
lations. It is an educational program developed jointly by the
American Academy of Pediatrics and the Brady Center to Pre-
vent Gun Violence (Washington, DC) to use when counseling
patients on the inherent risk of guns in the community.
During the 30-minute training presentation by 1 of us
(P.S.C.), each provider received a STOP 2 kit. The kit con-
sisted of a health care provider reference manual, family bro-
chures, and posters. The patient portions of the kit were printed
in both English and Spanish. The brochures in the packet were
identical to those given to families recruited to the interven-
tion group. Providers were instructed to comply with a stan-
dardized 1- to 2-minute message to the gun-owning partici-
pant families during the visit. Two simple messages were given
to all families in the intervention group in accordance with the
STOP 2 program: first, “a gun in your home is a risk to your
Table 1. Questions Pertaining to Guns in Baseline and Follow-up Questionnaires
Question Response Type
Baseline and follow-up questionnaire
Is there a gun (handgun or rifle) currently kept in your household? Yes/no/not sure
Have you discussed with your children what to do if they find a gun? Yes/no/not sure
How many guns are kept in the household? Choices to circle are 1, 2, 3, or more than 3
What type(s) of gun(s) is (are) kept in the household? Choices to circle are handgun, rifle, or both
Is (Are) the gun(s) kept loaded? Likert scale*
Is (Are) the gun(s) stored in a safe, in a lock box, or with a gun lock? (Specify which.) Write in
Does your child know where the guns are kept? Yes/no/not sure
Follow-up questionnaire only
Were any or all of the guns that you had 1 month ago removed from your household? Yes/no/not sure
The reason you choose to keep a gun in your household is Choices to circle are protection, sport/recreation,
required for occupation, collector, and other
Has your child’s doctor ever spoken to you about gun safety? Yes/no/not sure
Did your child’s doctor seem knowledgeable about gun safety? Yes/no/not sure
Was the advice your children’s doctor gave you helpful in deciding whether to keep
a gun in your household or how to store your gun?
Yes/no/not sure
*Likert scale responses are always, most of the time, some of the time, and never.
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family,” and second, “the safest thing is not to keep a gun in
the home, but if you keep a gun, unload it and lock it up.” A
Spanish language translator was available.
One week after providers were trained in gun-safety coun-
seling, the intervention group was recruited. Data were col-
lected and compared by using baseline and follow-up ques-
tionnaires. A timeline of the study is shown in the Figure.
INTERVENTION
All families in the intervention group received the physician
gun-safety counseling previously described, a STOP 2 family
brochure to reinforce the counseling, and a gun lock with printed
instructions on its use. Clinic staff clearly identified families
in the intervention group for the provider by attaching a STOP
2patientbrochureandagunlocktoeachmedicalrecordplaced
outside the examination room. The gun lock used in the study
was the Universal safeTclaw from Safegun Corporation (Forest-
ville, Md). It fits all handguns and long guns in all calibers and
has illustrated instructions. Its list price is $6.99.
One month after their respective enrollments, participants
in both the control and intervention groups were mailed a fol-
low-up questionnaire. The follow-up questionnaire ascer-
tained data regarding any removal of guns since enrollment along
with any changes in gun storage patterns. With regards to gun
storage patterns, subjects were asked about the frequency of
unloaded storage (gun lock–independent behaviors) as well
as the type and frequency of locked storage (gun lock–
dependent behaviors). Questions in the follow-up question-
naire regarding the presence of guns in the household and the
type and frequency of storage were identical to those in the base-
line questionnaire. Study subjects who did not return the fol-
low-up questionnaire after 2 weeks were contacted by a re-
search assistant and asked to complete the survey by telephone.
OUTCOME ASSESSMENT
The primary outcomes of this study were 2-fold. The first was
the removal of all guns from a household, which was ascer-
tained by asking, “Is there still a gun currently kept in your
household?” at follow-up. The second was the improvement
of gun storage by subjects who kept a gun in the household at
follow-up. Table 2 outlines the 4 different ways improve-
ment could occur and how each was defined.
Comparisons between the control and intervention groups
were made by using the "2test with a 2-tailed #!.05 consid-
ered statistically significant. We analyzed the outcomes of gun
storage behavior in 2 ways. First, we compared the percentage
in each group demonstrating improvement in each behavior
using the "2test. Second, we compared the change in baseline
and follow-up Likert scale responses using the Mann-
Whitney Utest.
None of the distributions of the potentially confounding vari-
ables were significantly different between the intervention and
control groups (P!.10). Because of our sample size, however,
we confirmed our findings using logistic regression, adjusting
for a teenager in the household, primary language spoken at
home, perceived danger of the neighborhood, and type of gun
in the household. None of these variables significantly altered
our results and are therefore not included. The investigational
review board of the El Rio Community Health Center ap-
proved the study.
RESULTS
Baseline questionnaires were completed by 2649 fami-
lies. Of these, 206 (7.8%) reported 1 or more guns at home.
Informed consent was obtained for 180 (87.4%) of these
gun-owning families. In the 26 cases where informed con-
sent was not obtained, all were due to oversight of the
research team rather than family refusal. Of the 180 con-
senters, 151 (83.9%) successfully completed both the base-
line and follow-up questionnaire. Overall, the study was
completed on 73.3% (151/206) of the original gun-
owning families. The percentage of families that re-
quired telephone follow-up was 41% in both the control
and intervention groups.
Baseline characteristics of control and intervention
groups were similar (Table 3) with the exception that
the control group was significantly more likely to have
proper storage of their guns at baseline (65.4% vs 46.6%,
P=.05). Mean Likert scale scores were similar at base-
line between the control and intervention groups with
regard to frequency of gun storage, use of storage de-
vices (including gun locks), and frequency of storing guns
unloaded (data not shown).
Did the intervention improve overall gun-safety prac-
tices? At follow-up, families who received the interven-
tion were more likely to have improved overall gun-
safety practices compared with the control group (61.6%
vs 26.9%; relative risk [RR], 2.29; 95% confidence inter-
val [CI], 1.52-3.44; P!.001).
Control Group
Received Usual
Anticipatory
Guidance
(n
=
78)
Follow-up
Questionnaires
1 Month After
Recruitment
Follow-up
Questionnaires
1 Month After
Recruitment
Provider Training
Session on Gun-
Safety Counseling
Intervention
Group Received
Gun-Safety
Counseling, STOP
2 Written Material,
and Gun Lock
(n
=
73)
Time, mo
0123
Figure. Study timeline. STOP 2 indicates Steps to Prevent Firearm Injury in
the Home.
Table 2. Type and Definition of Improvement in Safe Gun Storage
Type Definition
Any improvement One or more of the types of improvements listed below
Greater frequency of locked storage (the amount of time a gun
is stored with a gun lock and/or with a lock box)
A positive change in Likert scale score at follow-up compared
with baseline (never, some of the time, most of the time, always)
Improved type of gun storage A positive change in Likert scale score at follow-up compared
with baseline (none, lock box or a gun lock, lock box and a gun lock)
Greater frequency of storing gun unloaded A positive change in Likert scale score at follow-up compared
with baseline (never, some of the time, most of the time, always)
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Did the intervention decrease gun ownership? At
follow-up, 13 (16.6%) families in the control group and
16 (22%) families in the intervention group reported hav-
ing removed all guns from the home (RR, 1.31; 95% CI,
0.68-2.54; P=.41).Inaddition,8(10.2%)familiesinthe
control group and 7 (10%) families in the intervention
group reported removing some (but not all) guns from
the home (RR, 0.96; 95% CI, 0.54-1.70; P=.89).
Did the intervention improve safe gun storage? To as-
sess the impact of the intervention on families improp-
erly storing guns at baseline, we excluded all families who
at follow-up had removed all guns from their home. In
the next few paragraphs, we examine each variable of safe
gun storage as defined in Table 2.
When gauging any improvement, we found that
50.9% of respondents in the intervention group
improved either their gun lock storage frequency, their
gun storage type, or the frequency of storing a gun
unloaded. This was compared with 12.3% of those
respondents in the control group. This difference was
statistically significant (RR, 4.13; 95% CI, 2.06-8.30;
P!.001; Table 4).
Regarding the frequency of locked storage, 25% of the
intervention group showed some improvement at fol-
low-up in the frequency a gun was stored with a gun lock
or in a lock box compared with 4.8% of the control group
(RR, 5.20; 95% CI, 1.59-17.32; P=.003; Table 4). This
finding was confirmed by comparing the Likert scale
change between the 2 groups with the intervention group
having a significantly improved frequency of storage com-
pared with the control group (Mann-Whitney UTest,
P=.01).Because thecontrolgroup wasslightlymore likely,
although not significantly so, to always store guns with
a gun lock or lock box at baseline, we also repeated the
analysis with only those families who at follow-up still
owned a gun and at baseline were not always properly
storing their guns. The results remained similar with
greater improvement seen among the intervention group
(RR, 3.18; 95% CI, 1.10-9.19; P=.02).
With regard to the type of storage used, at follow-up
26.3% of the intervention group improved their type of
storage compared with only 3.1% of the control group
(RR, 8.55; 95% CI, 2.04-35.81; P!.001; Table 4). Again,
this finding was confirmed by comparing the Likert scale
change between the 2 groups with the intervention group
being significantly more likely to use a proper storage de-
vice at follow-up compared with the control group (Mann-
Whitney Utest, P!.001).
The frequency with which the families stored their guns
unloaded at follow-up did not significantly differ be-
tween the intervention and control groups (RR, 2.25; 95%
CI, 0.82-6.18; P=.11; Table 4). This finding was con-
firmed by comparing the Likert scale change between the
2groups(Mann-WhitneyUtest, P=.45). Becausethecon-
trol group was slightly more likely, although not signifi-
cantly so, to always store guns unloaded at baseline, we
also repeated the analysis with only those families who
at follow-up still owned a gun and at baseline were not
always storing their guns unloaded. The results re-
mained similar with no difference seen between the con-
trol and intervention groups (RR, 1.00; 95% CI, 0.49-
2.05; P=1.00; Table 4).
In all outcomes measured, no results were signifi-
cantly changed in multivariate analysis (data not shown).
However, those in the intervention group who owned a
handgun were more likely to show overall gun storage
improvement when compared with those who owned only
arifle(P!.05). None of the other variables listed in Table 3
predicted improved gun storage behavior.
Of the 43 families in the intervention group who were
not using gun locks at baseline, 12 (27.9%) were using
gun locks at follow-up. Of the 43 similar families in the
control group, 7 (14.9%) were using gun locks at fol-
low-up (RR, 1.45; 95% CI, 0.94-2.23; P=.13).
Table 3. Baseline Characteristics of Control
and Intervention Group
Characteristic
Control
Group
(n = 78)
Intervention
Group
(n = 73)
Child age, mean (SD), y 5.9 (5.4) 6.5 (5.9)
Households with at least 1 male child, % 71.1 80.0
Households with more than 1 child, % 73.7 74.6
Households with at least 1 teenager, % 39.0 45.5
Male head of household, % 84.2 82.1
Annual household income !$20 000, % 52.1 51.5
Spanish language, % 23.4 26.0
Own gun for protection, % 64.0 75.3
Perceive neighborhood as dangerous, % 15.4 11.0
Know any victims of violence, % 43.6 30.1
Guns in household, mean (SD), No. 1.9 (1.1) 1.6 (0.9)
Handgun owners, % 61.5 72.6
Gun always locked, % 74.3 63.0
Lock box or gun lock used for storage, % 64.1 72.6
Guns always stored unloaded, % 84.6 71.3
Gun lock usage, % 21.5 23.5
Proper gun storage, %*65.4 45.2
*Proper gun storage is defined as a gun that is always stored unloaded in
a lock box or secured with a gun lock.
Table 4. Percentages of Families Improving Gun Storage After Intervention Among Households Still With Guns at Follow-up*
Improvement
% (No./No.) Relative Risk
(95% Confidence
Interval) PValueControl Intervention
Any improvement in gun storage 12.3 (8/65) 50.9 (29/57) 4.13 (2.06-8.30) !.001
Greater frequency of locked storage 4.8 (3/63) 25.0 (14/56) 5.20 (1.59-17.32) .003
Improved type of gun storage 3.1 (2/65) 26.3 (15/57) 8.55 (2.04-35.81) !.001
Greater frequency of storing gun unloaded 7.8 (5/64) 17.5 (10/57) 2.25 (0.82-6.18) .11
*Each denominator represents those subjects who did not remove all guns from the household at follow-up. Each numerator represents those subjects who
showed improvement at follow-up with regard to the outcome being measured.
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COMMENT
This study provides reason to be optimistic about the ef-
fectiveness of a brief gun-safety counseling session, re-
inforced with written material and a gun lock giveaway.
Overall, those gun-owning families who received the in-
tervention were more than twice as likely to show some
type of improvement in their gun-safety practices. More
specifically, although our intervention did not appear to
significantly influence the removal of guns from the home,
it did significantly improve safe gun storage practices.
Of those who chose not to remove all guns from their
home, the greatest improvements were seen in gun lock–
dependent behaviors (type of storage and gun lock stor-
age frequency) as opposed to gun lock–independent be-
haviors (the frequency of unloaded storage). Given this,
one might speculate that the critical part of the interven-
tion was the gun lock giveaway. Although only one quar-
ter of the gun locks that were given out were reportedly
used, almost twice as many families in the intervention
group were using gun locks at follow-up compared with
the control group. This trend, however, did not reach sta-
tistical significance. A recently published study of gun
owners who were native to Alaska showed similar rates
of acceptance of free trigger locks.14
To our knowledge, this is the first trial of gun-safety
counseling in an outpatient pediatric setting that has
shown a positive effect of such an intervention. The
intervention fit into the time constraints of a health su-
pervision visit and was well received by providers and
patients. Given the gravity and pervasiveness of this pub-
lic health problem, our findings suggest that an in-
creased effort be made to address gun safety during well-
child visits.
Our finding that handgun owners were more likely to
improve gun storage behaviors compared with long gun
owners may make this group an especially good target for
further interventions, as suggested by the American Acad-
emy of Pediatrics recommendations for gun-safety coun-
seling. Considering that handguns account for the major-
ity of deaths and injuries from guns in the United States,15
any improvement in their storage could potentially lead
to a significant decrease in gun-related morbidity and mor-
tality. The STOP 2 program focuses on the danger of hand-
guns, and thus the improvements in storage might be re-
lated to the strength of that message.
We hypothesize that our results differ from prior stud-
ies showing educational interventions to be ineffective
because we formed a partnership with local law enforce-
ment that enabled us to give free gun locks directly to
gun-owning families along with counseling. The gun lock
might have provided a cue to action, which is felt to im-
pact health behavior decisions, that led to the desired gun
storage behaviors.16 Injury prevention efforts are most ef-
fective when combining an array of health education and
behavior change strategies such as counseling and the pro-
vision of subsidized safety devices.17
To our knowledge, this is one of only a few studies to
examine a gun-safety intervention in a predominantly His-
panic community.18 A previous survey has shown a gun
ownership rate of 14.7% among Hispanic families com-
pared with 43% of white families with children.12 This
is slightly higher than the 7.8% gun ownership rate in
our study. Data from the same survey, however, showed
lower gun ownership rates for families living in pov-
erty, families with lower education levels, and families
living in the western United States, all attributes of the
majority of families in our study.
This study has some limitations. Given the noncon-
current design, it is important to note that we know of no
significant community gun-related program or event that
occurred during the study period that might have influ-
enced the results. We were also limited by an assumption
that all guns in a given household were stored in a similar
fashion. Finally, reliance on self-report of behaviors can
introduce bias. This is especially relevant in this study given
the socially and politically charged nature of gun owner-
ship in this country coupled with the vulnerability some-
times felt by the Hispanic population in the Southwest.
However, the successful integration that the El Rio Com-
munity Health Center has achieved in its community and
the lack of child safety lock and child access prevention
laws in Arizona make us confident that such a bias is mini-
mized. Previous studies validate the self-reporting of gun
ownership,19,20 although evidence validating self-
reporting of gun storage patterns is lacking.
We found that a brief gun-safety counseling session
reinforced with written material and a gun lock give-
away resulted in improvement in safe gun storage prac-
tices. It did not, however, appear to significantly influ-
ence the removal of guns from the home. This study
provides support to the American Academy of Pediat-
rics recommendations to discuss gun safety with fami-
lies and encourages further research in this area.
Accepted for Publication: June 3, 2005.
Correspondence: Paul S. Carbone, MD, Children’s Pri-
mary Care Medical Group, 3702 Ruffin Rd, No. 205, San
Diego, CA 92123 (pcarbone@chsd.org).
Funding/Support: This study was funded by a grant from
the American Academy of Pediatrics Research in Pedi-
atric Practice Fund, Elk Grove Village, Ill.
Previous Presentation: This study was presented as a plat-
form presentation at the annual meeting of the Pediatric
Academic Society; April 3, 2004; San Francisco, Calif.
Acknowledgment: We owe thanks to the Brady Center to
Prevent Gun Violence, Washington, DC, for the donation
of Steps to Prevent Firearm Injury in the Home (STOP 2)
material. Additional thanks go to the Pima County attor-
ney’s office for donating the gun locks used in the study.
The assistance of Guimel Acton; Terry Brown; and Hector
Acton, MD, was invaluable in the completion of the study.
We also thank the administration, pediatricians, and nurs-
ing staff from the El Rio Community Health Center in Tuc-
son, Ariz, for their enthusiastic support and participation
in the study. We acknowledge Catherine Jolma, MD, for
her help in reviewing the manuscript.
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Treatment of influenza: quinine, the hydro-
chloride, daily as prophylactic, has specific
action as shown by experience with hussars
at Bonn during the epidemic of 1889-90.
Cinnamon is a valuable remedy, if used early
the patient will return to his usual avoca-
tions within 3 or 4 days.
—From Materia Medica Pharmacy and
Therapeutics, 1906
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