• Blood pressure (BP) should be measured using a validated and calibrated device, applying the correct technique, and following a consistent approach for each patient.
• Measuring BP outside the office is recommended for diagnostic purposes, particularly because it can detect both white coat hypertension and masked hypertension.
• If out-of-office measurement is not feasible, BP should be confirmed with repeated in-office measurements using the correct standardized technique.
• Most automatic oscillometric monitors have not been validated for BP measurement in atrial fibrillation (AF) cases; in these circumstances, consider measuring BP manually via the auscultatory method, when possible.
• Orthostatic hypotension (≥20 mmHg drop in systolic BP and/or ≥10 mmHg drop in diastolic BP 1 and/or 3 minutes after standing) should be assessed at least during the initial diagnosis of high BP or hypertension, and later if suggestive symptoms appear. The patient should lie down or sit for 5 minutes before the test

• A risk-based approach is recommended, considering individuals with moderate or severe chronic kidney disease, established cardiovascular disease, hypertension-mediated organ damage, diabetes mellitus, or familial hypercholesterolemia as being at higher risk for cardiovascular events.
• Regardless of age, individuals with elevated BP and a SCORE2 or SCORE2-OP cardiovascular risk of ≥10% should be considered at higher risk.
• For estimating cardiovascular risk in patients with type 2 diabetes mellitus and elevated BP, the SCORE2-Diabetes tool should be considered, especially for those <60 years old.
• Pregnancy complications are sex-specific risk modifiers and should be considered to up-classify patients with elevated BP and borderline 10-year CVD risk (5% to <10%).
• High-risk ethnicities (e.g., South Asian), family history of premature atherosclerotic disease, socioeconomic deprivation, inflammatory autoimmune disorders, HIV, and severe mental illness are shared risk modifiers for both sexes. These factors should be considered to classify individuals with elevated BP and increase their 10-year cardiovascular risk (5% to <10%).
• If treatment decisions to lower BP based on risk remain unclear after evaluating non-traditional cardiovascular risk modifiers and predicted 10-year cardiovascular risk, coronary artery calcium (CAC) scoring, carotid or femoral plaque via ultrasound, high-sensitivity cardiac troponin biomarkers, B-type natriuretic peptide, or arterial stiffness (pulse wave velocity) can be considered to improve risk stratification for patients with borderline 10-year cardiovascular risk (5% to <10%) after shared decision-making and cost considerations.

The 2024 ESC Guidelines for managing hypertension include the following suggestions:

• Regular BP monitoring with the following frequency:

-Adults <40 years old: at least every 3 years.

-Adults ≥ 40 years old: at least once a year.

• For people with elevated BP who do not meet treatment criteria, BP should be reassessed and risk reevaluated within a year.

• Other forms of hypertension screening, such as systematic detection, self-examinations, and screenings by non-medical personnel, may be considered depending on feasibility in different countries and healthcare systems.
• In individuals with higher cardiovascular risk, whose office BP is between 120–139/70–89 mmHg, ambulatory BP monitoring (ABPM) and/or home BP monitoring (HBPM) is recommended. If not feasible, repeated in-office BP measurements should be done over more than one visit.
• For patients with apparent resistant hypertension, treatment adherence should be assessed (via direct observation or detecting prescribed drugs in blood or urine samples) if resources are available.
• If moderate-to-severe chronic kidney disease is diagnosed, serum creatinine, estimated glomerular filtration rate (eGFR), and urine albumin-to-creatinine ratio (ACR) measurements should be repeated at least one a year.
• Coronary artery calcium scoring may be considered in patients with elevated BP or hypertension when it is likely to change patient management.
• Patients with resistant hypertension should be referred to specialized hypertension centers for further testing.
•  Patients with hypertension who show signs, symptoms, or medical history suggesting secondary hypertension should be appropriately screened.
• Primary aldosteronism screening via renin and aldosterone measurements should be considered for all adults with confirmed hypertension (BP ≥ 140/90 mmHg).

Here are some key recommendations from the 2024 ESC Guidelines for managing high BP and hypertension:

• To better predict adult hypertension and associated cardiovascular risk, timely BP monitoring should be done during late childhood and adolescence, especially if one or both parents have hypertension.
• Sugar intake should be restricted, and sugary drinks (e.g., sodas, fruit juices) discouraged from early childhood.
• In individuals with hypertension who are free of moderate-to-severe chronic kidney disease and consume high sodium levels, increasing potassium intake by 0.5 to 1.0 grams per day is recommended. Consider replacing regular salt with potassium-enriched salt or increasing fruit and vegetable consumption.
• For adults with elevated BP and low-to-moderate cardiovascular risk (less than 10% over 10 years), lifestyle changes are recommended to lower BP levels.
• In adults with confirmed elevated BP (≥130/80 mmHg) and high cardiovascular risk, pharmacological treatment is recommended after 3 months of lifestyle changes.
• BP-lowering treatment should only be considered from ≥140/90 mmHg in individuals who meet any of the following criteria:

– Symptomatic orthostatic hypotension (BP drop upon standing) before treatment

– Age 85 or older

– Clinically significant moderate-to-severe frailty

– Limited life expectancy (less than 3 years).

• For patients who cannot tolerate BP-lowering treatment well and cannot achieve a systolic BP of 120–129 mmHg, targeting a systolic BP level “as low as reasonably achievable” (ALARA principle) is recommended.

Effective management of hypertension requires a comprehensive approach that includes patient education, technological tools, and multidisciplinary collaboration. Below are several recommendations for improving blood pressure control, from the importance of clear doctor-patient communication to the use of home monitoring devices and the redistribution of responsibilities among healthcare professionals. These approaches not only simplify treatment but also enhance patient adherence to it.

• A clear discussion with patients about cardiovascular risk and treatment benefits, tailored to their needs, is recommended as part of hypertension management.
• Motivational interviewing techniques are suggested to help patients control their BP and improve treatment adherence at hospitals and community health centers.
• Physician-patient online communication is an effective tool that should be considered in primary care, including reporting home BP readings to physicians.
• Home BP monitoring is recommended as it helps better manage hypertension.
• Self-measurement of BP is recommended because, when done correctly, it has positive effects on accepting the hypertension diagnosis, patient empowerment, and treatment adherence.
• To manage hypertension more effectively, a multidisciplinary approach that safely delegates certain tasks from physicians to other healthcare professionals is recommended. This helps improve BP control and ensures more efficient care.

At SCHILLER, we are committed to helping healthcare professionals care for patients with high blood pressure and/or hypertension. That’s why we offer our DS-20 Diagnostic Station, an all-in-one device that seamlessly integrates EKG (including a 6-minute step test), blood pressure, and vital signs measurements into a single system. This Swiss-quality device provides the following features:

Most vital signs and physical assessment tools are united in one device: NIBP, TEMP, SpO2, 3-lead EKG.

Large 18” interactive touchscreen with intuitive guidance and easy-to-use interface.

Highest diagnostic EKG quality with a 32,000 Hz sampling rate (12-lead).

Bidirectional communication through Wi-Fi and Ethernet connection.

REFERENCE

John William McEvoy et al. 2024 ESC Guidelines for the management of elevated blood pressure and hypertension. European Heart Journal (2024) 00, 1–107 https://doi.org/10.1093/eurheartj/ehae178

Interstitial lung disease (ILD) is a general term that encompasses more than 200 respiratory diseases affecting normal lung parenchyma and associated with significant morbidity and mortality. Confirming a diagnosis requires a combination of criteria: clinical, radiological, and, in some cases, pathological.

The most common types of ILD that physicians may encounter are sarcoidosis, hypersensitivity pneumonitis, idiopathic pulmonary fibrosis, ILDs secondary to connective tissue diseases, drug-induced ILDs, and pneumoconiosis.

When discussing a positive diagnosis of diffuse interstitial lung disease, there are several steps that both the patient and the physician must follow to ensure greater diagnostic accuracy.

The evaluation of a patient with this condition begins with a high degree of clinical suspicion based on a detailed history and a thorough clinical examination. It can be stated that there are two main steps in establishing a positive diagnosis: the first step is to establish the diagnosis of ILD and differentiate it from other respiratory or non-respiratory diseases, and the second step is the etiological diagnosis of ILD.

This second step requires a series of extensive investigations, such as laboratory analyses, immune markers, lung function tests, chest HRCT exam, bronchoscopy, bronchoalveolar lavage, and, in certain situations, a lung biopsy. Of all these investigations, imaging (chest HRCT) is the key component for diagnosis, as it often provides essential information for diagnosis.

Once the physician has gathered all the necessary information, the ideal course of action is for the final diagnostic decision to be made by a multidisciplinary team.The gold standard in ILD diagnosis is considered to be a team composed of the following specialists:

• A respiratory physician
• A radiologist
• A pathologist
• A thoracic surgeon or a rheumatologist

The role of the rheumatologist within the multidisciplinary team has gained significance, especially in cases where a systemic autoimmune rheumatological disease is suspected. The input of this physician and the range of investigations they can suggest can make the difference between a correct and an incorrect diagnosis.

Perception Error by the Patient. The first diagnostic error can be the patient’s. Constitutional differences between individuals, their perception of the severity of symptoms, and individual fragility can lead them to attribute nonspecific symptoms to age or another condition. Added to this are the lack of access to specialized medical care and ignorance of symptoms. Therefore, the time window from symptom onset to final diagnosis can vary. A study by van der Sar et al.,shows that only 30% of patients with pulmonary fibrosis received a final diagnosis within 3 months; however, 40.2% of patients received a final diagnosis in a year or more.

The first consequence of an incorrect diagnosis for the patient is the delay in receiving the correct diagnosis and starting the appropriate treatment. The study by Marlies Wijsenbeek et al. shows a delay of more than 12 months before a positive diagnosis is made, and also that up to 55% of ILD patients are misdiagnosed.

On the other hand, the consequences of these incorrect diagnoses are reflected in the prescription of ineffective and possibly harmful treatments for the patient. According to some studies, patients who were diagnosed with other conditions received treatment with systemic corticosteroids, antibiotics, combinations of bronchodilators and inhaled corticosteroids, proton pump inhibitors, or antacid therapy. Interestingly, specific inhaled therapy was administered even to patients who did not meet the criteria for asthma or COPD.

Improving the process and shortening the time needed to establish an accurate diagnosis can be achieved by making changes at the patient level, medical staff level, facility level, and improving public access to these facilities, as well as by deepening clinical studies.

Regarding patients, these goals can be achieved through medical education, encouraging them to see a doctor when symptoms first appear without ignoring them or attributing them to other causes.

For healthcare professionals, the primary care physician plays an important role as they are often the first contact the patient has with the healthcare system. Therefore, it is essential that they carefully assess the symptoms and perform a clinical examination that includes pulmonary auscultation. Additionally, it is necessary to facilitate patient access to specialized diagnostic centers for ILD and improve the bureaucratic processes that delay referrals to specialists.

Discover the SpiroScout ultrasonic spirometer, the easy-to-use tool that helps assess pulmonary function accurately.

SOURCE

Raluca Ioana Arcana. Speaking of the “Devil”: Diagnostic Errors in Interstitial Lung Diseases. J Pers Med. 2023 Nov; 13(11): 1589. Published online 2023 Nov 10. DOI: 10.3390/jpm13111589

The 6-minute walk test (6MWT) is used to objectively assess the exercise capacity of patients with moderate to severe pulmonary diseases. Unlike pulmonary function tests, the 6MWT captures the often-coexisting extrapulmonary manifestations of chronic respiratory diseases, including cardiovascular diseases, frailty, sarcopenia, and cancer.

Unlike cardiopulmonary exercise testing, this test is low-complexity and safe. The patient is simply asked to walk as far as possible along a 30-meter corridor for a period of 6 minutes. The absolute distance in the 6MWT and changes in it are predictive of morbidity and mortality in patients with COPD, pulmonary arterial hypertension, pulmonary fibrosis, and other conditions. This underscores that the information obtained from this test is very useful in making management decisions for patients. In this blog, we discuss the fundamentals of the 6-minute walk test and its many clinical benefits.

As the name suggests, the goal of the 6-minute walk test is for patients to walk as far as possible for 6 minutes. The test should be conducted indoors, on a 30-meter long, flat, straight corridor with a firm, low-traffic surface. There should be a starting line marking the beginning and end of each 60-meter lap, the length of the corridor should be marked every 3 meters, and the turnaround points should be marked with a cone (such as an orange traffic cone). In general, the following aspects should be observed:

•  Patients should wear comfortable clothing and appropriate walking shoes. Additionally, they should use their usual walking aids during the test (such as a cane or walker), if applicable. They should not have engaged in intense exercise in the 2 hours prior to the test. However, a light meal is acceptable before tests conducted early in the morning or early in the afternoon. They should continue with their usual medical regimen.

• Patients should use their prescribed oxygen therapy and manage their oxygen delivery device. If this is not possible, the assessor should walk slightly behind to avoid setting the pace.
• It is important to record how patients were assisted with oxygen, as subsequent tests should be performed in the same manner.
• Oxygen should not be adjusted during the study, as supplemental oxygen and its portability affect exercise performance, and the distance walked.
• Patients should rest for at least 10 minutes before starting the test.

• During this time, blood pressure, heart rate, SpO2, and baseline levels of dyspnea and fatigue should be documented.

In 2002, the American Thoracic Society published its Clinical Practice Guidelines for the 6-Minute Walk Test. This document details the factors influencing the results, provides a brief step-by-step protocol for performing the test, describes the safety measures to be observed, proper patient preparation and procedures, and offers guidelines for interpreting the results. Among the most notable information contained in this document, we can mention:

Indications for the Test. The strongest indication for the 6MWT is to measure the response to medical interventions in patients with moderate to severe cardiac or pulmonary diseases. However, it also serves as a predictor of morbidity and mortality in patients.

Contraindications: Absolute contraindications include unstable angina within the previous month and myocardial infarction within the previous month. Relative contraindications include a resting heart rate of more than 120, a systolic blood pressure of more than 180 mm Hg, and a diastolic blood pressure of more than 100 mm Hg.

Other ATS guidelines

• Repeated tests should be performed at approximately the same time of day to minimize intraday variability.
• A warm-up period before the test should not be performed.
• The patient should sit at rest in a chair, located near the starting point, for at least 10 minutes before the test begins.

REFERENCES

[1] Priya Agarwala, Steve H. Salzman. Six-Minute Walk Test. Chest. 2020 Mar; 157(3): 603–611. Published online 2019 Nov 2. doi: 10.1016/j.chest.2019.10.014

[2] ATS Statement Guidelines for the Six-Minute Walk Test. https://www.atsjournals.org/doi/full/10.1164/ajrccm.166.1.at1102

 

Vaping as the Cause of EVALI (E-cigarette or Vaping Product Use–Associated Lung Injury), a pulmonary disease that can be severe and potentially life-threatening. The term was coined at the same time the disease was first recognized in August 2019. It is important to clarify that EVALI is not a clinical diagnosis but a case definition for surveillance.

 

Vaping can lead to a wide range of severe adverse health effects, including nicotine poisoning, injuries due to battery explosions from these devices, and damage to the gastrointestinal, cardiovascular, and neurological systems. The rapid adoption of this harmful practice, particularly among young people, has made EVALI a serious public health issue. In this blog, we summarize some of the most important points on this topic.

On the other hand, several definitions of EVALI have been proposed based on the combination of clinical characteristics and patient history. The most commonly used definition is based on the CDC guidelines, which were developed to assist in identifying probable and confirmed cases, thus allowing for standardized reporting and monitoring in the context of an outbreak. Clinically, patients develop hypoxemia that requires supplemental oxygen and signs of systemic inflammation indicated by leukocytosis.

Similarly, according to the document "Cardiopulmonary Impact of Electronic Cigarettes and Vaping Products: A Scientific Statement From the American Heart Association," there are three types of symptoms that are commonly present in cases of EVALI:

Prominent Gastrointestinal Symptoms. These have been a common primary complaint, affecting over 80% of patients.

General Systemic Symptoms. These include subjective fever, chills, and fatigue, which have been frequently reported.

Respiratory Symptoms. Most patients required some form of respiratory support, ranging from supplemental oxygen and non-invasive ventilation to mechanical ventilation and extracorporeal oxygenation.

In addition, the work of Georgios A. Triantafyllou mentions that during outpatient follow-up, the patients presented the following symptoms (remember that only 41 records were reviewed):

The long-term effects of EVALI have been minimally studied, but a cohort of 41 patients with one-year outcomes reported that 24% of them required hospital readmission. The one-year mortality rate was 4.9%, and 45% continued to experience symptoms during outpatient follow-up. Although most imaging findings improved or resolved during follow-up, 75% of patients with pulmonary function tests showed abnormalities after having EVALI.

Due to the novelty of this syndrome, there are no clinical trials for potential therapies yet, so the current treatment is primarily supportive and based on those used for similar diseases. The document from the American Heart Association⁴ mentions the following:

• Most patients diagnosed with EVALI were initially managed in inpatient services.
• More than half presented with severe illness requiring admission to the intensive care unit.
• The majority of patients (78%–100%) required some level of supplemental oxygen during hospitalization.
• Severe respiratory failure is common in these patients, with the highest level of respiratory support including high-flow nasal cannula (up to 47%), non-invasive positive pressure ventilation (up to 30%), and endotracheal intubation and invasive mechanical ventilation (up to 22%).
• Severe cases of EVALI have required venovenous extracorporeal membrane oxygenation, with one case progressing to a lung transplant.
• According to another review of 169 published articles on EVALI, the majority of patients (95%) required hospitalization and most (84%) received glucocorticoids.
• Glucocorticoids were used in many cases and may be beneficial in the treatment of EVALI. Dosage regimens varied widely.
• The administration of glucocorticoids may be justified in severely ill patients when deemed safe and feasible, and when concomitant infection has been ruled out; however, no clinical trials have been conducted to evaluate their effectiveness.
• Patients have recovered without receiving glucocorticoids. Most patients underwent a thorough microbiological and viral infection assessment.
• Between 78% and 100% of patients received empirical antibiotic therapy, at least initially, in the cases.
• Recurrent cases of EVALI have been reported with persistent use of electronic nicotine delivery systems (ENDS), therefore, cessation is essential for these patients.

* Please note that SCHILLER may modify the product’s design, specifications, and features or discontinue a specific product at any time without notice or obligation. The images displayed are for representation purposes only. Device availability in your market is subject to regulatory approval.

[1] Meghan E. Rebuli et al. The E-cigarette or Vaping Product Use–Associated Lung Injury Epidemic: Pathogenesis, Management, and Future Directions: An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc. 2023 Jan 1; 20(1): 1–17. Published online 2023 Jan 1. doi: https://doi.org/10.1513/AnnalsATS.202209-796ST

[2] Hubert Mado et al. The vaping product use associated lung injury: is this a new pulmonary disease entity? Rev Environ Health. 2020 Dec 7;36(2):145-157. DOI: https://doi.org/10.1515/reveh-2020-0076

[3] Georgios A Triantafyllou et al. Long-term outcomes of EVALI: a 1-year retrospective study. Lancet Respir Med. 2021 Dec; 9(12): e112–e113.

Published online 2021 Oct 25. doi: 10.1016/S2213-2600(21)00415-X

[4] Jason J. Rose et al. Cardiopulmonary Impact of Electronic Cigarettes and Vaping Products: A Scientific Statement From the American Heart Association. Volume 148, Issue 8, 22 August 2023; Pages 703-728 https://doi.org/10.1161/CIR.0000000000001160

 

 

Oscillometry, or the Forced Oscillation Technique (FOT), measures the mechanical properties of the respiratory system (i.e., the upper and intrathoracic airways, lung tissue, and chest wall) during resting breathing by applying an oscillating pressure signal.

Oscillometry measures the mechanical impedance of the respiratory system (Zrs), which represents the resistive and reactive forces that must be overcome to introduce an oscillating flow signal into the respiratory system. These forces arise from three sources in the respiratory system:

1. The resistance of the airways and tissues to flow (Rrs).

2. The elastance (stiffness) of the lung parenchyma and chest wall in response to volume changes (included in the reactance, Xrs).

3. The inertia of the accelerating gas in the airways (Irs).

The impedance of the respiratory system is generally reported at a single frequency or within the frequency range of 5 to 40 Hz on average, throughout the entire respiratory cycle (i.e., both inspiration and expiration). It has also been reported separately during the inspiratory and expiratory phases.

The impedance of the respiratory system (Zrs) evaluates the relationship between pressure and flow changes during oscillatory flow into and out of the lungs. Zrs has two basic components: resistance (Rrs) and reactance (Xrs). To provide a clearer understanding of respiratory impedance, we offer the following image and a brief explanation:

Oscillometry is a useful test for diagnosing pediatric and adult asthma patients, to detect the degree of obstruction affecting the airways, and to distinguish asthma from COPD. It can also help support an asthma diagnosis, predict future asthma control loss, or guide clinical treatment modifications.

Furthermore, oscillometry provides insights into asthma pathophysiology through the effects of lung volume on oscillatory mechanics, as well as short-term and long-term variations in mechanics over time. These variations can serve as markers of instability, making them potentially valuable for detecting exacerbations or loss of control.

Intrabreath changes in oscillometry parameters can also provide additional information beyond conventional parameters. For example, in preschool-aged children, the use of this test improved the detection of patients with acute obstruction and recurrent wheezing compared to healthy controls. Meanwhile, in adults with severe asthma, it allowed differentiation between patients with poor disease control and those who were well controlled.

Oscillometry and spirometry help diagnose and monitor many lung diseases, such as asthma and COPD, two of the most common diseases affecting millions of people. According to the 2024 GINA Report, asthma affects approximately 300 million people worldwide and causes 1000 deaths daily.

Regarding COPD, while obtaining definitive figures is challenging, the 2024 GOLD Report estimates a global prevalence of COPD of 10.3% (95% confidence interval (CI): 8.2%, 12.8%).

Generally, in hospital wards, nurses check patients’ vital signs with several hours between each check (approximately every 2 to 4 hours). Due to the intermittent nature of these checks, there is a risk of overlooking abnormalities in vital signs that typically precede serious adverse events.

Early warning scores combining various vital signs are better predictors of severe adverse events than individual vital signs alone. Thanks to connectivity advancements, there are now vital signs monitors that automatically calculate trends, providing healthcare professionals with a comprehensive view of the patient’s condition. Some of the vital signs that carry significant weight in outcomes include:

This device allows you to monitor: EKG (3 or 5-lead), Heart Rate NIBP, Temperature, SpO2 (Digital or Masimo) and Respiration.

Having reliable vital signs monitors improves outcomes and, consequently, patient satisfaction. Additionally, it reduces nurses’ workload and the costs associated with emergency interventions and potential negligence claims if a patient passes away. Discover the effective vital signs monitoring solutions offered by SCHILLER.

REFERENCES

[1] Bernd Saugel et al. Automated Continuous Noninvasive Ward Monitoring: Validation of Measurement Systems Is the Real Challenge. Anesthesiology. March 2020, Vol. 132, 407–410. DOI: https://doi.org/10.1097/ALN.0000000000003100

[2] Frederic Michard et al. Rethinking Patient Surveillance on Hospital Wards. Anesthesiology September 2021, Vol. 135, 531–540. https://doi.org/10.1097/ALN.0000000000003843

[3] Zhuo Sun et al. Postoperative Hypoxemia Is Common and Persistent: A Prospective Blinded Observational Study. Anesth Analg.2015 Sep;121(3):709-715. doi: 10.1213/ANE.0000000000000836

[4] Alparslan Turan et al. Incidence, Severity, and Detection of Blood Pressure Perturbations after Abdominal Surgery: A Prospective Blinded Observational Study. Anesthesiology. 2019 Apr;130(4):550-559. DOI: 10.1097/ALN.0000000000002626

[5] Daryl A Jones. Rapid-response teams. N Engl J Med. 2011 Jul 14;365(2):139-46. DOI: 10.1056/NEJMra0910926

[6] John P Abenstein, Bradly J Narr. An ounce of prevention may equate to a pound of cure: can early detection and intervention prevent adverse events? Anesthesiology. 2010 Feb;112(2):272-3. DOI: 10.1097/ALN.0b013e3181ca858d

[7] Daniel Sessler Preventing respiratory depression. Anesthesiology. 2015 Mar;122(3):484-5. DOI: 10.1097/ALN.0000000000000565

[8] Patrick G Lyons et al.Characteristics of Rapid Response Calls in the United States: An Analysis of the First 402,023 Adult Cases From the Get With the Guidelines Resuscitation-Medical Emergency Team Registry. Crit Care Med. 2019 Oct;47(10):1283-1289. DOI: 10.1097/CCM.0000000000003912

[9] The International Surgical Outcomes Study group. Global patient outcomes after elective surgery: Prospective cohort study in 27 low-, middle-, and high-income countries.Br J Anaesth. 2016 Oct 31;117(5):601-609. DOI: 10.1093/bja/aew316

 

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