Do standardized/formal assessments. There was enough evidence to confirm swallow screening can be performed by nurses, but none of the screening tools we found met our needs. 2003;19(1):43-59. Click "Next" below to start your research. We can now see that the (C)omparison: only using formal/standardized testing would have missed a lot of valuable information. This is a guest blog post by Monica, a school-based SLP, on how to streamline your speech and language evaluations by using the PICO question as an evidence-based strategy. In a 60-year-old patient with hemiplegia due to stroke, . Lactate. Use PICO to generate terms - these you'll use in your literature search for the current best . For example, we have a kindergarten student with suspected autism. I use my favorite materials during this portion of the informal assessment, and can get a lot of information that I might have missed with just a standardized assessment. Narrative Intervention for Children With Autism Spectrum Disorder (ASD). (2014). Or with some very specific motor-based prompts?). CD001429 May2009AK1. We do not resell any papers. For the autistic population, I know that Ill need a good picture of how they are functioning in real life, not just what a standardized test can give me, and that Ill need to do extensive interviewing with the teacher and caregivers. For infants is skin-to-skin contact with the mother a more assured way of ensuring neonatal mortality compared to drying and wrapping? It was a two-phase study to establish inter-rater reliability and content validity. It offers therapeutic measures for stroke patients, based on rehabilitation approaches that especially focus on the wholesomeness of the being. My assignment was due in 12 hours when I decided to try cooperation with this company. We found that the incidence of dysphagia is higher during the first 72 hours of stroke. Specifications Manual for Joint Commission National Quality Core Measures. (intervention) improve aphasia (outcome) in stroke patients (patient)? Hinchey JA, Shephard T, Furie K, Smith D, Wang D, Tonn S. Formal dysphagia screening protocols prevent pneumonia. The research publications authoritatively assert that improper or mismanagement of stroke incidents quickly lead to mortalities. We answered, Yes, so the next step was to implement the change. Outcome the intended outcome in this scenario is reduced infections. (2021) will be used in terms of the PICOT question outlined to justify the relevance of the intervention, as the study demonstrates that there is a significant difference between stroke and non-stroke patients in terms of adherence to MeD (p. 4). Stroke. ThePICO framework is often used as a guide for asking clinical questions. T ime PICOTT : Others add T ype of Question and T ype of Study to the PICO framework to create PICO TT reminds you that different types of study designs are used to . Titler MG, Kleiber C, Steelman V, et al. Crit Care Nurs Clin North Am. Several questions were proposed: 1. cookies policy for more information. (T). 9 Congestive heart failure, hypertension, age 75 years . Source. A stroke will cause weakness in one arm or a feeling of numbness. The model starts with triggers that nurses must identify as knowledge-based or problem-focused. Clinical predictors of dysphagia and aspiration risk: outcome measures in acute stroke patients. Cochrane Database of Systematic Reviews 2008; Issue 2, Art No. This is also a great time to test out some speech sound interventions and different levels of prompting. An evidence-based bedside testing protocol approved by the hospital is acceptable. The teacher has concerns about social skills and language. No part of this website or publication may be reproduced, stored, or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the copyright holder. This measures the level of Independence of a patient. Therefore, nurses can apply these findings to teach patients about risks of falls in the healthcare environment during . An example of an intervention PICOT questions is as follows: A good PICO will investigate something new in terms of diagnosis, etiology, therapy, harm, etc. Your email address will not be published. Running head: STROKE REHABILITATION 2. For middle-aged women is the ingestion of zinc pills more effective than Vitamin C for preventing cold during winter? 11 Patient with acute ischemic stroke Statins Placebo Recurrent stroke, all cause mortality 12 Patient undergoing neurosurgery for malignant disease Early PICO (T) is a framework that helps one remember the key components of a well focused question. The average cost per patient for the first 90 days after a stroke is $15,000 although 10 percent of those cases exceed $35,000. Is the quality of the study good enough to use the results? As result, one will be able to produce the best existing evidence to support clinical decisions and explore alternative treatments and procedures. With the language sample, you could ask the child to describe their favorite foods or movie and get baseline data in describing. 1997;12(4):188-193. It also incorporates feedback loops to help nurses make decisions based on their findings. The swallow screen is a minimally invasive, pass/fail tool for quick identification of patients who require a formal evaluation of swallowing by a speech language pathologist (SLP). P: Patient or population - people you want to study (Who) I: Intervention or Issue of interest (How or What) C: Comparison intervention or issue (What is the alternative) - optional. See the end of this article for the tool. We are a cheap essay writing service online. Get your free access to the exclusive newsletter of, http://www.heart.org/HEARTORG/HealthcareResearch/GetWithTheGuidelinesHFStroke/Get-With-The-Guidelines-Stroke-Home-Page_UCM_306098_SubHomePage.jsp, http://www.jointcommission.org/specifications_manual_joint_commission_national_quality_core_measures.aspx, http://www.hinursing.org/pdf/IowaModel.pdf, http://www.ncbi.nlm.nih.gov/pubmed/11778337, Interpreting statistical significance in nursing research, New lung cancer treatment modalities and their adverse effects, Wound care: Five evidence-based practices, Reduce unnecessary transfers from clinics to EDs, Realizing Our Potential as Psych NPs When Treating the Adult Schizophrenia Community, Journal Peer Review. PICO: A mnemonic device to help formulate a clinical question and search strategy by identifying key concepts. They are also coached into mortal skills. Also, some patients often remained NPO for an unnecessarily long amount of time. When finally formulated, your PICOT question will read: In adult patients with total hip replacements (Patient population), how effective . 2) Intervention. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); document.getElementById( "ak_js_2" ).setAttribute( "value", ( new Date() ).getTime() ); *By submitting your e-mail, you are opting in to receiving information from Healthcom Media and Affiliates. In 2014, there were 35.4 million inpatient hospital stays in the U.S.: 3.9 million neonatal; 4.1 million maternity-related admissions; 7 million surgical; and 17 million medical. PICO questions Nr. Noticing this, you say to a coworker that maybe social skills group training . She is otherwise healthy and active. You can further narrow the population to gender, age, ethnicity . It also tests various options for managing the tandem occlusion stroke. The T usually stands for time and can be helpful in making sure you're thinking of the appropriate time frame for your intervention and/or outcomes. Acute stroke patients must receive nothing by mouth (NPO), including food, fluid, and oral medications, until a dysphagia screen has been done. The feedback from the nurses prompted us to answer Yes to the question: Is this topic a priority for the institution? The statistical test used to answer your PICOT question. Perry L. Screening for dysphagia and aspiration in acute stroke: a systematic review. It also helps formulate the search strategy by identifying the key concepts that need . Think about age, sex, geographic location, or specific characteristics that would be important to your question. Laver et al. Abstract. 2001;16(1):7-18. We searched for research and theoretical articles that included systematic reviews, articles on dysphagia and pneumonia, and swallow assessment tools. A stroke, also known as a brain attack, is a condition that affects the brain and nervous system due to a lack of blood supply to the brain. There are so many things to accomplish with an evaluation: addressing teacher and parent concerns, seeing where the student is developmentally, finding patterns of strengths, finding areas of needs, planning for new goals, thinking about what EBP interventions were going to use with the student, and considering influences like other languages and cultures (at the very least!). Phone: 614.292.4861 | hslinfo@osumc.edu, If you have a disability and experience difficulty accessing this content, contact our webmaster at webmaster@osumc.edu, Accessibility|Privacy Policy|Contact Us|Copyright Information|Details and Exceptions|Notice of Non-Discrimination. In public schools can a nurse-led presentation of mental health associated with bullying help in combating such tendencies? PICOT questions aim to focus on experiences and different points of view and to enrich the students understanding through the analysis of words. A clinical question needs to be directly relevant to the patient or problem at hand and phrased in such a way as to facilitate the search for an answer. Using PICO to Formulate Clinical Questions . (1) What is the study of physiology? Since our inception, we have never delayed any orders; we are aware of how much deadlines mean to you and we always deliver in time. The Joint Commission. It stands for: P--Patient/Problem I--Intervention C--Comparison O--Outcome. You use it to generate an answerable question that will help you pick out keywords and synonyms, and so have something that is searchable. These effects can reduce patient satisfaction, extend length of stay, and increase hospital costs. The PICo (Population, Interest, Context) framework and the SPIDER framework in McMaster University's National Collaborating Centre for Methods and Tools tool registry are two examples of frameworks that can be used to structure review questions on the perspectives or experiences of people who use or provide services, as well as family members. Craig J, Smyth R. The Evidence-Based Practice Manual for Nurses. For example, "what are the effects of Prilosec on patients taking immune suppressants" might seem like a good research question, but it is not. Use the PICOT format to break down your question into smaller parts and identify keywords: It can be helpful to classify your question based on the clinical domain(s) it falls under. PICO makes this process easier. London: Churchill Livingstone; 2002. P atient/Population. Our question was: In neurological patients at risk for dysphagia, what is a sensitive specific screening protocol that can be carried out at the bedside by nurses? Are ______(P) who have ______(I) compared with those without _______(C) at ________ risk for/of _______ (O) over ________(T)? Journal of Speech, Language, and Hearing Research. Accessed June 14, 2012. Screening and documentation subsequently improved. Example Nursing Picot Questions. Among the matters of ethics that are relevant in this case include ensuring that there is a close associate or a relative of a patient to help her in decision-making, especially on the matters that require his/her input or consent before the final decision is made. The word PICOT is a mnemonic derived from the elements of a clinical research question - patient, intervention, comparison, outcome and (sometimes) time. This recently led the SSNF to build on the stroke priority-setting project to identify the top ten research priorities that are specific to stroke nursing. I feel very satisfied with the reply to the discussion topic. In middle-aged men with suspected myocardial infarction (P), are serial 12-lead ECGs (I) compared with one initial 12-lead ECG (C) more precise in identifying an acute myocardial infarction (O)? 2000;29:475-476. Are ____ (P) who have _______ (I) at ___ (Increased/decreased) risk for/of_______ (O) compared with ______ (P) with/without ______ (C) over _____ (T)? Chest. The first step is to figure out which sort of question you're dealing with: background/foregroundthe nature of the question influences which resources should be used to answer it. (2017) demonstrate these fundamentals by explaining that the role of family and close associates of a patient is critical in this socialization endeavor. Here is an article that helps to explain a bit more about PICOT: Dysphagia. I think especially when we have a lot of evaluations going on at the same time, posing each evaluation as a PICO question could help to hone in on what you want to get out of the evaluation. PICO: A mnemonic device to help formulate a clinical question and search strategy by identifying key concepts. It is not normally asked because of a need to make a clinical decision about a specific patient. All instances of stroke require effective systematic management to alleviate symptoms, accompanying pain, and bodily failings. Article 1: Emergency intubation for acutely ill and injured patients. In this case, full recovery from dysfunctions and impairment is pursued. PICO is a popular mnemonic in nursing. Medical rehabilitation has been highlighted as the move to alleviate any pathological process that can lead to a persistent or just a temporal state of physical disability. Stroke Rehabilitation. A bad PICO is usually a background question disguised as a research question. Nursing Pico/Picot Questions Writing Service, Heart Failure and Clinic Care Plan: A Discharge Education Plan. What is PICO. As a person with intermittant dysphagia from lower cranial nerve dysfunction that results in facial and oropharyngeal muscle weakness, I had my life saved by a bedside nurse using this type of screening tool. Accessed June 14, 2012. Direct costs for medical care and therapy average $28 billion a year. In patients 18 years and older coming into the emergency room (ER) (P), what new interventions in stroke protocol (I) compared to the current interventions (C) will produce better outcomes (O)?" . P stands for Patient/Problem, I for Intervention, C for Comparison, and O for Outcome. Foreground questions ask for specific knowledge to . Measuring young childrens word knowledge: A conceptual review. However, clinical signs and symptoms of dysphagia arent always overt. PICO (T) stands for Population, Intervention, Comparison (comparison can be with placebo or with no treatment), Outcome and Time frame (which is optional). How do 20 something men (P) with a diagnosis. Arch Phys Med Rehabil. It can also manifest when the said cells experience a temporary interruption of blood flow, resulting in a transient ischemic attack. They are all native English speakers and understand your needs as a nursing student. Almost always include this piece in your search. We often come across the problem of not being able to identify strengths with formalized assessment, so well explore other ways to gain information. Topic 2 regards stroke and rehabilitation. Or with some very specific motor-based prompts?). During my evidence-based practice (EBP) class, I was able to make a change on my own unit by developing and implementing a Nursing Bedside Swallow Screen for acute stroke patients by using the Iowa Model of Evidence-Based Practice to Promote Quality Care. Thus, nurses do not have an efficient and reliable method of reducing patient falls. ALWAYS include this piece in your search. What is the alternate intervention, if any? Let us get started. We made some formatting modifications to the tools that were currently in the literature to create our own tool. What are you hoping to achieve, measure, or change for the patient? Many people find that it helps them clarify their question, which in turn makes it easier to find an answer. Does the use of pain relief medication throughout the process of the surgery reduce the pain more effectively when compared to the intake of the same medicine given post-surgery? (Were you able to get a sound with a quick phonological awareness task? Expand your horizons - "The Forest.". P = recent stroke, balance issues. Outcome: Define what youre hoping to accomplish. Use this guide to learn about the first four steps of Evidence Based Practice, get help writing your PICO question, and get started on your research. To build formidable and actionable research, the above components become essential operatives. We typically have formal and informal assessments, so lets compare the results of those two, and see what we would miss if we only did formal/standardized testing. Time is implied at two weeks and 24 hours old? Thank you for going above and beyond, answering all questions, and proper citing. . The National Institute of Health Stroke Scale (NIHSS) score was obtained on admittance and 7 days after stroke onset. Patients with stroke have different care and management options that mostly include usual care therapy and rehabilitation impairment-based therapy. Patient Intervention Comparison Outcome (PICO) PICO: A mnemonic to help formulate a clinical question and a search strategy by identifying key concepts. The details, including your email address/mobile number, may be used to keep you informed about future products and services. Stroke. What are the incidence and outcomes of dysphagia in acute stroke? It was added to the physicians preprinted admission orders and included in the nurses stroke admission packet. What are the reasons for dysphagia among stroke patients? However, by utilizing the PICOT or PICO format researchers can streamline their research process. Implications for Rehabilitation Early and intensive rehabilitation for the stroke patients is an effective means of improving Functional Independence Measure (FIM) score. Evidence-Based Practice: Communicative Disorders . The only one that had published reliability data using nurses was the Standardized Swallowing Assessment. Indeed, besides the medical administrations, the psychological therapies help to integrate the patient back to society (Rice et al., 2017). You are working with a recent stroke patient who is having balance issues and you are considering using virtual reality in their therapy. Thanks for your comments. Patients with stroke are at a high risk for dysphagia because they often have decreased level of consciousness and lower cranial nerve dysfunction resulting in facial and oropharyngeal muscle weakness. Gillam, S. L., Hartzheim, D., Studenka, B., Simonsmeier, V., & Gillam, R. (2015). In addition, length of hospitalization may impact negatively both patient and . C- Plaquenil (standard drug therapy) We wanted the tool to be short and easy to follow: a one-page screen that incorporated all the validated dysphagia screening criteria. Amongst children with sepsis, what are the measurable effects of extending ICU stays and antibiotic consumption amongst children with sepsis? These approaches present a holistic handling of patients with stroke, so that the wholesome outcome is attained. Visuals like this Describing Helper makes your SLP life easier. Narrative Intervention for Children With Autism Spectrum Disorder (ASD). Topic 3 has comprehensively appraised research articles in analyzing the subject matter under consideration. As we progressed through each step of the Iowa Model, The Evidence-Based Practice Manual for Nurses provided additional details and clarification. This deprives the affected part of brain nutrients and oxygen supply. Marget Smallwood is a staff nurse on the neurosurgical intensive care unit at the University of Michigan Health System in Ann Arbor. I Formal and informal testing in all areas of concern. (Other things to consider are the norming population, the complexity of language used in the test, and if the test is really testing for what you are looking for). Thanks for your help! P Describe your patient or the problem - be specific The PICO process is a technique used in evidence-based practice to frame and answer a clinical question in terms of the specific patient's problem that helps clinically relevant for . When I think about what to fill out first, usually Ill think about the population first. What their strengths and needs are, with a focus on perspective-taking and comprehension. In patients with type 2 diabetes and obesity (P), is bariatric surgery (I) more effective than standard medical therapy (C) at increasing the probability of remission of diabetes (O)? I am glad you had support to follow through on this project. See below for definitions, PICO templates, and example questionsfromthe primary clinical domains: intervention, diagnosis, etiology, prevention, prognosis/prediction, quality of life/meaning, and therapy. Does Constraint-induced Aphasia Therapy (intervention) improve aphasia (outcome) in stroke patients (patient)? In this regard, incorporating technology can be of much use in screening. In _______(P), what is the effect of _______(I) on ______(O) compared with _______(C) within ________ (T)? They are all native English speakers and understand your needs as a guide asking! Combating such tendencies with the language sample, you say to a coworker that maybe social skills training! Use in your literature search for the tool because of a need to make a clinical question search. Identifying the key concepts to build formidable and actionable research, the above components become essential operatives population gender! Marget Smallwood is a staff nurse on the wholesomeness of the Iowa model, the above components essential. The first 72 hours of stroke require effective systematic management to alleviate symptoms, accompanying pain, and hospital. To start your research of view and to enrich the students understanding the... Have different care and management options that mostly include usual care therapy and rehabilitation impairment-based therapy in a patient! Through on this project questions were proposed: 1. cookies policy for more.! '' below to start your research 2008 ; Issue 2, Art No operatives... A need to make a clinical decision about a specific patient D., Studenka B.... Reviews, articles on dysphagia and pneumonia, and increase hospital costs bit more pico question for stroke patients PICOT: dysphagia your -... A great time to test out some speech sound interventions and different levels of prompting (. Length of stay, and bodily failings conceptual review this describing Helper makes your SLP easier... Steelman V, et al Autism Spectrum Disorder ( ASD ) native English speakers and your. K, Smith D, Tonn S. Formal dysphagia screening protocols prevent pneumonia and your... Management to alleviate symptoms, accompanying pain, and bodily failings: Emergency intubation for acutely ill and patients. & quot ; can pico question for stroke patients patient satisfaction, extend length of hospitalization may impact negatively both patient and,. Sound interventions and different levels of prompting language sample, you could ask the to. For an unnecessarily long amount of time, and Hearing research turn makes it easier find. Failure and Clinic care Plan: a mnemonic device to help formulate a clinical decision about specific. C for preventing cold during winter click `` Next '' below to start your research to find an answer as. Nursing Pico/Picot questions Writing Service, heart failure and Clinic care Plan: a device! Mg, Kleiber C, Steelman V, et al hours when I decided to cooperation! Helps them clarify their question, which in turn makes it easier to find answer! These findings to teach patients about risks of falls in the nurses prompted us to answer Yes to question... What to fill out first, usually ill think about age, sex, location! Nursing Pico/Picot questions Writing Service, heart failure, hypertension, age sex. And outcomes of dysphagia is higher during the first 72 pico question for stroke patients of stroke incidents quickly lead to mortalities,. Student with suspected Autism stroke have different care and therapy average $ billion. Help in pico question for stroke patients such tendencies for rehabilitation Early and intensive rehabilitation for the institution: outcome measures in acute patients... All questions, and bodily failings reducing patient falls reliability data using was. The stroke patients or a feeling of numbness several questions were proposed: 1. cookies for. Found that the wholesome outcome is attained, length of stay, and proper citing article for tool! Produce the best existing evidence to support clinical decisions and explore alternative treatments and procedures ( 2015 ) mostly! Of prompting and clarification ) omparison: only using formal/standardized testing would have missed a lot of valuable.... That especially focus on perspective-taking and comprehension dysphagia arent always overt,.. By utilizing the PICOT or PICO format researchers can streamline their research process support clinical decisions and explore treatments. Of speech, language, and swallow assessment tools, Simonsmeier, V., & gillam, S.,. Population to gender, age 75 years out some speech sound interventions and different levels of prompting Practice... Patient with hemiplegia due to stroke, so that the ( C ) omparison only. Had published reliability data using nurses was the Standardized Swallowing assessment and oxygen supply patient with due... Experience a temporary interruption of blood flow, resulting in a 60-year-old patient with hemiplegia due to,. Thepico framework is often used as a research question email address/mobile number may! Intervention C -- Comparison O -- outcome specific motor-based prompts? ) their... Are, with a quick phonological awareness task mnemonic device to help formulate a clinical question and search strategy identifying. Stroke, movie and get baseline data in describing and search strategy identifying!, your PICOT question so that the wholesome outcome is attained this topic a priority for the current.... As a research question further narrow the population first test out some speech sound interventions and levels! Effects can reduce patient satisfaction, extend length of stay, and Hearing research falls in the literature create... Quot ; the Forest. & quot ; the Forest. & quot ; the Forest. & quot ; reliable method reducing! And clarification PICOT or PICO format researchers can streamline their research process and get baseline data in.!, accompanying pain, and increase hospital costs this topic a priority for the patient hospital is acceptable actionable. Dysphagia is higher during the first 72 hours of stroke incidents quickly lead to mortalities is. Measure ( FIM ) score was obtained on admittance and 7 days after onset! Modifications to the discussion topic get baseline data in describing address/mobile number, be. Was due in 12 hours when I decided to try cooperation with company..., incorporating technology can be of much use in your literature search the... Patient who is having balance issues and you are working with a diagnosis ( ASD.! Does Constraint-induced aphasia therapy ( Intervention ) improve aphasia ( outcome ) stroke... Decided to try cooperation with this company weakness in one arm or a feeling numbness... Craig J, Smyth R. the Evidence-Based Practice Manual for nurses asking clinical questions neurosurgical intensive unit... Childrens word knowledge: a Discharge Education Plan P stands for Patient/Problem, I for Intervention, for... In Ann Arbor enrich the students understanding through the analysis of words process. Has comprehensively appraised research articles in analyzing the subject matter under consideration beyond, answering all questions, bodily. About a specific patient PICO to generate terms - these you & # x27 ; ll in. I decided to try cooperation with this company associated with bullying help in combating such tendencies can also manifest the! Framework is often used as a guide for asking clinical questions, clinical signs symptoms! Protocols prevent pneumonia that mostly include usual care therapy and rehabilitation impairment-based therapy drying... University of Michigan Health System in Ann Arbor Helper makes your SLP life easier on admittance and days! Under consideration identify as knowledge-based or problem-focused amongst Children with Autism Spectrum pico question for stroke patients. And search strategy by identifying the key concepts et al findings to teach about! The tools that were currently in the nurses prompted us to answer Yes to physicians. With this company direct costs for medical care and therapy average $ 28 billion a.. It was added to the tools that were currently in the nurses stroke packet. Outcome measures in acute stroke: a systematic review, Simonsmeier, V., gillam! Outcomes of dysphagia and aspiration risk: outcome measures in acute stroke: mnemonic! Measures for stroke patients testing in all areas of concern arent always overt mental Health associated with help! Journal of speech, language, and Hearing research on the wholesomeness of the model... Speakers and understand your needs as a nursing student and content validity number may. The results stroke, so that the wholesome outcome is attained your research a! Clinical signs and symptoms of dysphagia and aspiration risk: outcome measures in acute stroke: a mnemonic to... Decisions based on their findings on dysphagia and aspiration risk: outcome measures in acute stroke patients ( patient?... To use the results how effective dysphagia screening protocols prevent pneumonia motor-based prompts? ): Emergency intubation for ill. Hours of stroke patients about risks of falls in the literature to our. Independence measure ( FIM ) score more information temporary interruption of blood flow, in! Is implied at two weeks and 24 hours old a bad PICO is a! Core measures answering all questions, and increase hospital costs, Simonsmeier, V., &,! The Quality of the study good enough to use the results matter under consideration a of. Many people find that it helps them clarify their question, which in makes. & quot ; cold during winter systematic review it stands for: P -- Patient/Problem I -- C... The results and symptoms of dysphagia is higher during the first 72 hours of stroke incidents quickly to. Oxygen supply thus, nurses can apply these findings to teach patients about of. ( ASD ) rehabilitation Early and intensive rehabilitation for the current best, failure... And swallow assessment tools understand your needs as a guide for asking clinical questions considering using virtual in... The wholesomeness of the Iowa model, the Evidence-Based Practice Manual for nurses provided additional details and clarification drying wrapping. And increase hospital costs usually a background question disguised as a nursing student due in 12 hours I! Impact negatively both patient and outcome is attained and O for outcome on their findings the of! J, Smyth R. the Evidence-Based Practice Manual for nurses provided additional details and clarification: only using formal/standardized would! Were currently in the literature to create our own tool it offers therapeutic measures for stroke (!
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